Pregnancy: How much Vitamin A and/or beta-Carotene is appropriate

March 25, 2005

Introduction:

http://www.willner.com/References/vitapreg.htm

A woman who was planning a pregnancy came to Willner Chemists and asked one of

our Pharmacists for guidance on a nutritional supplement program. We recommended

a broad spectrum multivitamin multimineral supplement, and essential fatty acid

formula, and extra folic acid.

When she showed this to her Doctor, he apparently responded in a very negative

manner, frightening the woman by telling her that the product contained toxic

and dangerous levels of vitamin A and beta-carotene.

The product, in fact, supplied 5,000 IU of vitamin A and 15,000 IU of

beta-carotene, which is quite appropriate in a prenatal vitamin regimen.

Her Doctor, of course, is entitled to his own opinion, as misguided or

ultra-conservative as some might consider it to be. But I think he did the

patient a disservice by presenting his opinion in the way he did. She was, in

fact, so frightened by his response, that she claimed to be considering legal

action against us.

Comments:

This incident troubled me, both because I feel this particular woman has been

mistreated, and perhaps ill-advised by her physician, and because she was so

quick to dismiss out of hand my attempt to clarify the matter.

Perhaps more importantly, however, is that if she was given conflicting

information, others probably are experiencing the same problem.

It is an important, and potentially confusing area of nutritional support, so is

probably a worthwhile topic for both a radio show, and a reference Ahealth note@

article in the Willner Reference Catalog.

Contents:

Following the Aconclusion@ paragraph, you will find:

Appendix A. A table of Vitamin A/Carotene levels in Anatural@ PreNatal Vitamin

supplements

Appendix B. An excerpt from the September 3rd, 2000 Willner Window radio program

Appendix C. A compilation of reference excerpts from a wide variety of experts

and sources dealing with vitamin A and beta carotene usage during pregnancy

Conclusions:

Adequate Vitamin A intake during pregnancy and lactation is important. The

amount is a matter of balance.

Too much vitamin A, as actual, preformed vitamin A (vitamin A Palmitate, cod

liver oil, etc) should be avoided during pregnancy and during the period of

pre-conception.

But the definition of Atoo much@ is primarily a matter of speculation.

As will be seen from the following compilation of references, the estimate of

what is safe and what is not safe is based primarily on animal data,

epidemiological studies, and subject to considerable interpretive latitude and,

perhaps, bias.

There is no question but that one wants to err on the side of caution when

evaluating dosage levels of a nutrient that may affect fetal development.

But too little vitamin A can lead to problems as well.

The data that follows shows that most experts recommend a level of vitamin A

during pregnancy that ranges from 4,000 IU to 10,000 IU. My personal

recommendation, a bit more on the cautious side, would be 4,000 IU to 8,000 IU

of vitamin A.

What is important is to avoid over-reaction. It is silly to think that 3,900 IU

of vitamin A is optimal and safe, and that 4,200 IU is toxic and dangerous!

It is unrealistic to believe that 4,000 IU is a safe and effective level and

that 5,000 IU is dangerous and toxic.

It is also clear that there is little reason to fear taking moderate amounts of

natural beta carotene.

Except for the general caution that during pregnancy we should avoid massive

amounts of any and all nutrients, drugs, herbs etc, there is no evidence that

intake of carotenoids in the range 10,000 IU to 20,000 IU poses any danger.

The information presented herein is not intended as a substitute for the advice

and guidance of your physician. To the contrary, you should consult with your

physician, and follow his/her advice.

If you are concerned that your physician is being over cautious or conservative

when it comes to diet and/or nutritional advice, we encourage you to share this

information with your doctor.

Donald P. Goldberg, R.Ph.

Appendix A: Levels of vitamin A and beta-carotene in selected Anatural@ prenatal

vitamin supplements

Product Name

Vitamin A

Carotene

Total

Folic Acid

Iron

Calcium

Magnesium

I.U.

mcg

mg

Nature's Way Prenatal

825

7,425

8,250

400

9.0

250

125

Twinlab Pre-Natal

4,000

400

22.5

650

225

Nature's Plus Ultra Prenatal

10,000

800

36.0

600

225

New Chapter Perfect Prenatal

8,000

800

18.0

195

68

Now Prenatal Caps

10,000

800

36.0

1,200

500

Eclectic Opti Natal

5,000

10,000

800

50.0

1,000

500

Solgar Prenatal Nutrients

3,000

5,000

8,000

800

45.0

1,300

450

Natrol PreNatal Care

2,500

5,000

800

25.0

250

125

Rainbow Light Complete Prenatal

4,000

8,000

800

20.0

600

900

Willvite

5,000

15,000

20,000

400

9.0

1,000

500

Appendix B: Excerpts from the introductory remarks on the September 3rd Willner

Window Radio Program, WOR 710 AM.

Don: Good evening everyone, and welcome to the Willner Window. I=m Don

Goldberg...

Michele: ...and I=m Michel Levine, along with Don tonight at the WOR studios.

Arnie Gitomer is on vacation this week, but we have Dr. Richard Podell back with

us once again...

Richard: Thanks Michele, good evening everybody...

Don: I had a call from a customer last week that disturbed me... She had called

and asked one of our Pharmacists for some advice. She was anticipating beginning

a family, and hoped to soon become pregnant. She wanted to know which

nutritional supplements she should take.

As far as I am concerned, she was given very good advice. We told her to take

Willvite, Total EFA, and extra Folic Acid.

Now, here is the problem. When she showed these products to her doctor, he told

her that they contained toxic levels of vitamin A, and, basically scared the

bejeeebers out of her.

She called us, and was very upset. She was convinced that we were guilty of

trying to poison her and her baby, etc, and even threatened to sue us.

I tried to explain that this was, of course, not the case. I tried to explain

that the product Willvite only contained 5,000 IU of Vitamin A, not 20,000 IU,

and that this level of vitamin A was fine, and that 15,000 IU of beta-carotene

was fine as well. But she would have nothing to do with my explanation.

She had a book. And the book said that too much beta-carotene was toxic during

pregnancy as well. I tried to point out that Atoo much@ of anything during

pregnancy can be bad, but that the levels of carotenoids we are talking about

here is nowhere near Atoo much.@

Still, she dismissed my comments. Her book said not to take more than 5000 IU

(?) of carotene, and that was that! A...Do I know how many copies of this book

are in circulation? ...it is the most widely used book for pregnant women!@

Michele: It sounds like a fun conversation!

Don: Well, I know you are joking when you say that, Michele, but it bothered me

a lot. And here is what bothers me.

It=s not that her physician was wrong. This is not really a right or wrong

situation. Maybe he is anti-supplement. Maybe he is just mis-informed. Or maybe

he is just very conservative. That=s ok.

Michele: I would say that what was wrong was for him to present his opinion to

her in such a strong manner, in a way that created such alarm and fear in her

mind!

Don: Exactly, Michele. That is what bothers me as well.

I certainly would not tell her not to mind the advice of her physician. I might

give my opinonBI do it all the time. We do it here on the radio show, but we

always suggest that the final actions be done in cooperation with your doctor if

at all possible. We very rarely over-rule a doctor...

Michele: ...well, that=s an interesting point, because in this case, the initial

advice was provided to her by a registered pharmacist. In effect, the doctor

maybe unknowinglyBover-ruled the pharmacist.

Don: Yes, but I don=t really want to explore that side of it, because that is

not really what concerns me.

You know, there are still doctors, and dietitians, who advise their patients

that anything over the RDA is bad. They think that a multivitamin that only

provides 30 mg of vitamin C and 1 or 2 mg of B1 or B2 is all anyone needs, and

anything more is fraud!

You would have a hard time finding a multivitamin at Willner Chemists that

contains such low potencies...

Michele: ...which makes me wonder why she asked us for guidance in the first

place...

Don: I wondered about that as well, but I assume that it was the Doctor=s

reaction, and the Abook@ she bought, or was givenBI suspect the book was given

to her, published by a diaper company, or infant formula manufacturerBthat

changed her mind so drastically.

No, what bothers me the most is that she believes we misled her. And, it=s

something of an insult.

When I tell somebody that up to 8,000 IU of vitamin A is considered safe during

pregnancy, and that 5,000 IU is certainly no problem, and they dismiss what I

say as if I don=t know what I=m talking about, I must admit to feeling a little

miffed.

Michele: So you are going to get even by talking about her on the radio show!?

Don: Ha Ha... no, not really Michele. I intend to make two points during this

discussion. The first, which we have probably already made clear, is that it is

a mistake to assume that these topics can be so black and white.

This is the case whether you are talking about alternative medicine vs

conventional medicineBanybody who follows the medical news knows that all too

often what conventional medicine thought was true one day is found to be not

true the nextBor, if you are talking about the remedies or vitamins themselves.

By the very nature of most of these things, there is no one, fixed, defined

dose. There are just general guidelines. This starts all the way back with the

RDA=s themselves. A panel of experts looks at data, often animal data, and makes

an estimate of how much nutrient is required to prevent deficiency.

Periodically, they re-convene, evaluate new findings or just bow to peer

pressure, and change the RDA.

How much of a nutrient is needed to provide optimal health, as compared to

preventing deficiency? No one knows for sure. We see studies, for example, using

Vitamin E at levels up to thousands of IU, we see people recommending Vitamin C

at from 30 mg to 10,000 mg.

How much is too much? Can too much of a vitamin be toxic? In most cases, it

would be hard to take a toxic dose, because they are so safe. But the

fat-soluble vitamins can be a concern. The reason is that they accumulate in the

body, rather than being excreted...

Michele: ...and, before you continue, Don, ...there is the theory of Roger

Williams, regarding what he terms Abiochemical individuality@, where each of us,

according to him, has a unique requirement for each nutrient, and as we don=t

know what each requirement is, we should take an excess of all of them, to

ensure optimal health...

Don: Right Michele. But let=s finish this up by going to the question of

toxicity, especially during pregnancy.

Contrary to what this woman=s doctor told her, it is generally accepted that

5,000 IU of vitamin A, and 15,000 IU of beta-carotene is appropriate during

pregnancy.

In response to her challenge, what I have done is go through a bunch of

reference books, putting together a compilation of appropriate quotations and

excerpts from various doctors and nutritionists, dealing with vitamin A and

carotenoids during pregnancy.

I also spent some time searching the medical literature. The results were

surprising, and I will tell you why I say that after we take a short break.

Michele: OK, Don. Let=s do that. I will just remind the listeners that we will

start taking your calls as soon as we finish this discussion. If you have any

questions about vitamins, herbs, homeopathy and health problems, give us a call

at 1-800-321-0710. That=s 1-800-321-0710.

....Ok, welcome back everybody.... The phone number here is 1-800-321-0710

Michele: OK, Don, you wanted to finish up your comments on Vitamin A supplements

and pregnancy...

Don: Yes, Michele. First, I came up with a long list of books that support what

I told the customer, that she was given appropriate information about the level

of vitamin A that is safe during pregnancy, around the 5,000 IU level. And the

references also support my comment to her that moderate supplementation with

carotenoids or beta-carotene is not only safe, but often recommended as an

alternative to vitamin A.

As much as I would like to read samples of those excerpts right now, I realize

we don=t have the time. So what I did was prepare a listing of the excerpts, and

have posted them onto the Willner Chemists web site.

If you are interested in reading this, here is what you do. Go to

www.willner.com. Then go to the Areference library@ section, and scroll down the

list, looking for one titled AVitamin A & Pregnancy@ It will be near the top.

Also, I will publish this in the next catalog, but that will not be out for

another month or two.

Michele: That=s great, Don. But you said you discovered something surprising

when you did the literature search...

Don: Yes, Michele. First, I was reminded what brought this question of vitamin A

back into the public eye several years ago. It was an article published in the

New England J of Medicine, back in 1995...

Actually, before I mention that, I should point out that it really goes back to

the discovery that certain drugs,

which were synthetic analogs of vitamin A,

and used to treat things like acne, caused birth defects.

Most of the information on vitamin A, before this, was based on animal studies.

Once they found that these vitamin A-like drugs caused birth defects in humans,

then the question was, does natural vitamin A do the same thing?@

So these folks at Boston University School of Medicine did a study. But it was

the kind of study based on after-the-fact questionnaires! In other words, they

interviewed 22,700 women who underwent screening by amniocentesis or blood

tests. Nurses asked them a bunch of questions, including diet, medications, etc.

Then, they obtained information on the outcome of the pregnancy from either the

doctors or the women themselves.

They grouped the women according to the amount of vitamin A total, and the

amount in supplement form. The groups were more than 15,000 IU daily, less than

5,000 IU daily, and so on.

Their conclusion was that high intake of dietary vitamin A Aappears to be@

related to increased risk of birth defects. They came to the conclusion that

10,000 IU of vitamin A was the threshold point.

Michele: That=s interesting. Studies of this type are known to be potentially

unreliable. The conclusion was based upon recollections from an interview? I

would think that pregnant women, if anything, would have a tendency to answer

questions in a way that showed them in a good light, which would involve

embellishing dietary intake, and perhaps also embellishing supplement intake.

....and, perhaps, not admitting to doing many things that we know are unhealthy

to a fetus, such as using drugs, smoking, drinking, and so on.

Don: Yes, that is one problem with this type of study. The other problem is that

the results may be related to some other factor altogether. Women who take

supplements, for example, may tend to do other things as well...

Michele: Right, Don. We know that health factors like this are related to income

levels, level of education, and so forth.

Don: But again, Michele. I do not want to challenge the conclusions. When it

comes to pregnancy, I agree that it is best to err on the side of caution. Even

if the birth-defect question is not proven, if it seems likely, that is enough,

and I have no problem in cautioning against high levels of vitamin A if this

might be a problem.

Michele: But lets get back to the woman whose Doctor scared the heck out of her

because she was going to take a supplement that supplied 5,000 IU of vitamin A.

Didn=t you just say that they authors of that study identified a threshold of

10,000 IU of vitamin A?

Don: Exactly, Michele. And that may be why most experts that I am familiar with

recommend staying below 10,000, or 8,000 IU of vitamin A. Using a maximum of

5,000 IU or 4,000 IU is ok, but it is a very cautious, conservative guideline.

And that is ok with me.

Michele: But didn=t you say that this Doctor told the woman that 5,000 IU, which

is the amount provided in Willvite, was Atoxic,@ and that she shouldn=t take it?

Don: That=s right! Don=t ask me why. And when I told her this, and that the

remaining 15,000 IU was from natural beta-carotene, she said that was bad as

well, and more than her Abook@ said was acceptable.

This, too, is just not true. As you will see from the information I prepared in

the reference library, beta-carotene is the recommended form of vitamin A during

pregnancy, and at levels that range up to 25,000 IU.

But we are taking up more time with this than we should. Let me get to the

surprise. I=m sure her Doctor knew about the New Eng J Med study, but I wonder

if he knows about the studies that have been done since then?

I wonder if he knows that a study published in 1998, in the Int J of vitamin

Nutr Research, indicated that a dose of 30,000 IU of vitamin A per day seemed to

not be a level that caused birth defects?

I wonder if her Doctors knows about another study published in 1998, in the same

journal, that doses of vitamin A, at a level of 10,000 IU and lower, not only

did not cause increased birth defects, but also seem to have some protective

effect on the fetus?

Michele: I wonder if her Doctor is familiar with the study you have here that

was done in 1999, published in the journal, Teratology, that found that Ahigh

vitamin A intake,@ which for them was from 10,000 to 300,000 per day, Adid not

provide evidence for an increased risk of major malformations.@

And I wonder if her Doctor is familiar with the paper published in Reproductive

Toxicology, in 1998, that has as its objective, Ato determine whether preformed

vitamin A (retinol and retinyl esters) is teratogenic at dosages commonly used

by women living in industrialized countries.@ ? The conclusion was that women

taking 30,000 IU of vitamin A had levels of retinoids in the blood that was no

different than women during the first trimester who delivered healthy babies.

And, Don, the final comment in this paper published just over a year ago is, and

I quote: AInterestingly, neither teratogenicity nor vitamin A toxicity has been

observed in multiple species exposed to high doses of beta-carotene.@

Don: I know, Michele. And that certainly runs counter to what this doctor told

the lady, and to what she read in her widely read book.

I would really like to keep quoting these studies, but I will limit myself to

one more study. This one was published just this past July, in the journal of

Reproductive Toxicology. Very briefly, the conclusion was that safe levels of

Vitamin A during human pregnancy ran between 25,000 to 37,000 IU per day!

Now, am I saying you should take more than 5,000 to 8,000 IU of preformed

vitamin A during pregnancy. No. I remain very cautious in this regard, even

though evidence seems to indicate that higher levels may be ok.

Do I think it is wrong to scare a pregnant woman by saying 5,000 IU of vitamin A

and 15,000 IU of natural beta-carotene is toxic? I sure as heck am saying that!

If her Doctor had said that he prefers a more conservative approach, and prefers

an even lower level, that is fine. That=s his prerogative.

I strongly urge any of you who might have an interest in this subject to check

out the references I provided. I hope the customer and her Doctor do so.

Michele: To read Don=s research on Vitamin A, Carotene and Pregnancy, you can do

one of two things. One is to log onto the Willner Chemists web site, at

www.willner.com, and go to the reference library section. Once there, just

scroll down to the article titled Vitamin A & Pregnancy.

Or, you can wait until the next Willner catalog comes out. It should be

available in about 1 and 2 months. If you are on the Willner mailing list, you

will get it automatically. If not, just call 1-800-633-1106 and leave your name

and address.

Appendix C: Excerpts and reference articles:

Beta-Carotene should be used instead of Vitamin A during Pregnancy

A...Excess of preformed vitamin A has been linked to birth defects in animals

(beta-carotene should be used instead). Some vitamin A derivatives that are used

for skin problems should not be taken...@

Kirschman & Kirschmann, Nutrition Almanac, 4th Edition, Nutrition Search, Inc.,

McGraw-Hill, 1996 (pg 322).

Vitamin A important in reproduction and fertility

AVitamin A is related to sexual development and reproduction. It is essential in

the chemical process whereby cholesterol is converted into female estrogens and

male androgens. Insufficient supply of these sex hormones results in

degeneration of the sex organs. Animals in this condition that were given

vitamin A resumed normal hormone activity. Studies conducted on men having

varying levels of sperm deficiency showed that when vitamin A was administered

along with vitamin E, the sperm levels returned to normal.

AIf taken during pregnancy, both etretinate (found in traces in the body after 2

years) and accutane (leaves the body in a week or less) have the ability to

cause birth defects and should be avoided by women of childbearing age.

Etretinate derivatives are being developed for women in this category. Another

derivative of vitamin A, Retin A, recognized as the first breakthrough in the

line of cosmeceuticals, can be applied directly to the skin to help reduce the

signs of aging (photoaged skin).@

Kirschman & Kirschmann, Nutrition Almanac, 4th Edition, Nutrition Search, Inc.,

McGraw-Hill, 1996 (pg 3.

Avoid more than 10,000 IU Vitamin A during pregnancy; beta-Carotene cannot cause

overdose!

ASafety: Excess consumption of vitamin A in either supplement form or in cod

liver oil may result in toxicity. Pregnant women should not take over 10,000 IU,

and children should avoid over 18,000 IU. Taking beta carotene cannot result in

a vitamin A overdose. Note: Anyone with diabetes or hypothyroidism should not

take beta carotene as it cannot be converted to vitamin A@

Barney, Paul M.D., Doctor=s Guide to Natural Medicine. Woodland Publishing, 1998

(pg.33)

Adequate intake of Vitamin A is important during pregnancy.

APregnancy-Related Complications: Vitamin A: A lack of this vitamin has been

linked to lung disease in the developing infant and low levels also seem to play

a reole in developing toxemia.@

V. Hustead et al, ARelationship of vitamin A (retinol) status to lung disease in

preterm infant,@ Jour Ped, 1984, 105(4):610-15, as reported in Barney, Paul

M.D., Doctor=s Guide to Natural Medicine. Woodland Publishing, 1998 (pg. 327)

Safety Issues: Vitamin A Levels, and Beta Carotene Safety

AWomen must avoid vitamin A supplementation during pregnancy. A recent study

published in the prestigious New England Journal of Medicine demonstrated that

dosages greater than 10,000 I.U. during pregnancy (specifically during the first

7 weeks after conception) have probably been responsible for 1 out of each 57

cases of birth defects in the United States. Women who are at risk for becoming

pregnant should keep their supplemental vitamin A levels below 5,000 I.U. or,

better yet, look to carotenes.70

AAccidental ingestion of a single large dose of vitamin A (100,000 to 300,000

I.U) produces acute toxicity in children, resulting in raised intracranial

pressure with vomiting, headache, joint pain, stupor, and occasionally

papilledema. Symptoms rapidly subside upon withdrawal of the vitamin, and

complete recovery always results.'

AVitamin A toxicity may occur in adults who take in excess of 50,000 I.U. per

day for several years. Smaller daily doses may produce toxicity symptoms if

there are defects in storage and transport of vitamin A, which occurs in

cirrhosis of the liver, hepatitis, protein calorie malnutrition, and in children

and adolescents.71,72 Signs of vitamin A toxicity generally include dry,

fissured skin; brittle nails; alopecia; gingivitis; cheilosis; anorexia;

irritability; fatigue; and nausea. Serum levels of vitamin A of 250 to 6600 I.U.

per deciliter are typical of toxicity. Prolonged, severe hypervitaminosis A

results in bone fragility and thickening of the long bones.

AToxicity is typically encountered during high dose vitamin A therapy for

various skin conditions. Although dosages below 300,000 I.U. per day for a few

months rarely cause toxicity symptoms, early recognition is still very

important. Cheilitis (chapped lips) and xerosis (dry skin) generally appear in

the majority of patients, particularly in dry weather. The first significant

toxicity symptom is usually headache, followed by fatigue, emotional lability,

and muscle and joint pain. Laboratory tests are of little value in monitoring

toxicity because serum vitamin A levels correlate poorly with toxicity, and SGOT

and SGPT are elevated only in symptomatic patients. 34

AOn the other hand, supplementing the diet with beta-carotene does not produce

any significant toxicity despite its use in very high doses in the treatment of

numerous photosensitive disorders. Occasionally, patients complain of " loose

stools, " but this usually clears up spontaneously and does not necessitate

stopping treatment. Elevated carotene levels in the blood do not lead to vitamin

A toxicity, nor do they lead to any other significant disturbance besides a

yellowing of the skin (carotenodermia). The ingestion of large amounts of

carrots or carrot juice (.45 to 1.0 kilograms of fresh carrots per day for

several years) can, however, cause a neutropenia as well as menstrual

disorders.73,74 Although the blood carotene levels (221 to 1,007 micrograms per

deciliter) of these patients did reach levels similar to those of patients

taking high doses of beta-carotene (typically 800 micrograms per deciliter), the

disturbances were because of some other factor in carrots. Neither these

effects nor any others have been observed in subjects consuming very high doses

of pure betacarotene over long periods of time- e.g., 300,000 to 600,000 I.U.

per day (180 to 360 milligrams beta-carotene, which is equivalent to 4 to 8

pounds of raw carrots).75-79 Doses up to 1,000 milligrams per kilogram of body

weight have been given to rats and rabbits, for long. periods of time with no

signs of embryotoxicity, toxicity, tumorigenicity, or interference in

reproductive functions.10 "

Murray, Michael N.D., Encyclopedia of Nutritional Supplements. Prima Publishing.

1996, (pg 37)

A combination of Vitamin A and Carotenes is recommended

AStudies of the effects of vitamin A and beta-carotene on cancer have correlated

a decreased risk of cancer more often with a high beta-carotene intake than with

a high intake of the vitamin A in fish liver oil. Since active vitamin A (from

fish liver oil) and beta-carotene may have slightly different functions in the

body, I recommend that my patients take a combination of beta-carotene and

active vitamin A. My clinical experience has shown this combination to be most

effective. Palmitate, the synthetic form of vitamin A, is water miscible (water

soluble), and is therefore preferable for people who have difficulty absorbing

fats.

A There are over 400 carotenoids, the best known of which are beta-carotene,

lutein, canthaxanthin, zeaxanthin, lycopene, alpha-carotene, and cryptoxanthin.

Although not all of them have vitamin A activity, many have powerful antioxidant

properties and specific anticancer and cardiovascular-protective effects.

Therefore, I now recommend a natural beta-carotene supplement with mixed

carotenoids.@

Lieberman, Shari Ph.D and Bruning. The Real Vitamin & Mineral Book, 2nd ed.

Avery. 1997 (pg 70)

Vitamin A caution; beta-carotene virtually without risk!

AAll forms of active vitamin ABboth fat- and water-solubleBare stored in the

liver. This supplement can, therefore, be toxic in large amounts. In general, a

normal healthy adult must take at least 100,000 IU of vitamin A daily for a

period of months in order to display any signs of toxicity. Early signs of

toxicity are fatigue, nausea, vomiting, headache, vertigo, blurred vision,

muscular incoordination, and loss of body hair. Although all of these symptoms

are reversible when vitamin A supplementation is stopped, I would not recommend

this dose unless you are under professional guidance.

ABeta-carotene, on the other hand, can be given for long periods of time

virtually without risk of toxicity. Since beta-carotene is a naturally occurring

pigment, the only adverse effect of taking too much beta-carotene is the

possibility of carotenemia, a harmless condition in which the skin turns a

slight orange color. This is a signal that the body has converted as much

beta-carotene to active A as it can, leaving the excess as an orange-yellow

pigment. I often tell my patients that if they get carotenemia, they can cut

back, on their beta-carotene intake. On the other hand, such pigments are often

given to sun-sensitive individuals, since the tinting of the skin affords some

additional protection against sunburn. Carotene preparations are also used by

some people for a cosmetic effect. The slight tint looks like a suntan, and also

allows them to tan more easily and keep the tan longer. And, as we have seen,

high levels of carotenoids may also be protective against skin cancer.@

Lieberman, Shari Ph.D and Bruning. The Real Vitamin & Mineral Book, 2nd ed.

Avery. 1997 (pg 71-2)

Ok to take up to 8,000 IU vitamin A during pregnancy

AIf you are pregnant or lactating, do not exceed 8,000 international units of

vitamin A per day, as vitamin A may cause birth defects or be toxic to the

infant.@

Lieberman, Shari Ph.D and Bruning. The Real Vitamin & Mineral Book, 2nd ed.

Avery. 1997 (pg 71)

Beta-carotene is devoid of significant toxicity, even at extremely high doses

Although high, doses of preformed vitamin A can have toxic effects,

beta-carotene is mercifully devoid of most toxicity. Even among patients using

extremely high doses of beta-carotene (300 milligrams or 500,000 IUs daily) for

prolonged periods there was no significant toxicity.

Hendler, Sheldon Saul M.D., Ph.D. The Doctors= Vitamin and Mineral Encyclopedia.

Simon & Shuster, 1990 (pg 41)

Doctors wrong to warn patients away from vitamin A and carotene

AVitamin A, even in the wake of all its " miracles, " continues to be the most

feared vitamin. It is surprising how many physicians, still, warn patients to

stay away from vitamin A, neglecting to mention that beta-carotene, available

for several years now without prescription, has the same benefits as preformed

vitamin A and almost none of its, adverse side effects.@

Hendler, Sheldon Saul M.D., Ph.D. The Doctors= Vitamin and Mineral Encyclopedia.

Simon & Shuster, 1990 (pg 41)

Preformed Vitamin A can be toxic, but at what level? ...and beta-carotene?

A...Preformed vitamin A is unquestionably toxic in high doses, although these

usually have to be maintained for long periods before signs of toxicity begin to

appear. There is a high degree of variability from one individual to another.

Some take 50,000 IUs of vitamin A daily for years without apparent difficulty,

while a few may react adversely to a single 20,000 IU capsule. Signs of toxicity

include headaches, blurred vision, nausea, hair loss, itchy eyes, aching bones

and sores on the skin. These symptoms usually subside rapidly once vitamin A

intake is reduced or discontinued. Beta-carotene, on the other hand, has

extremely low toxicity. Vitamin A derivatives that are being marketed as

prescription drugs have some of the same toxicity as preformed vitamin A but,

when properly administered under the supervision of a physician, can usually be

tolerated sufficiently well to achieve the desired therapeutic effects.

Hendler, Sheldon Saul M.D., Ph.D. The Doctors= Vitamin and Mineral Encyclopedia.

Simon & Shuster, 1990 (pg 47)

....a few cases of defects linked to daily intake of 40,000 IUs (or more) have

been reported in humans. There is no evidence that beta-carotene, at any dose

level, produces birth defects...

APreformed vitamin A has been linked to birth defects in various animals. In

humans, a few cases of defects linked to daily intake of 40,000 IUs (or more)

have been reported. There is no evidence that beta-carotene, at any dose level,

produces birth defects. Pregnant women, however, should not take any drug,

vitamin, mineral or food supplement without first consulting their physicians.

Accutane and etretinate, as previously discussed, can produce birth defects and

must not be used under any circumstances by pregnant women or those women of

childbearing age who are not using contraception. Women of childbearing age are

advised not to use etretinate at all since it remains in the body long after its

use is discontinued.

Hendler, Sheldon Saul M.D., Ph.D. The Doctors= Vitamin and Mineral Encyclopedia.

Simon & Shuster, 1990 (pg 47)

virtually no evidence that... up to 15,000 IUs will pose any real risk, even in

children

AThe U.S. RDA is based on the assumption that vitamin A will be derived in whole

or part from preformed vitamin A, the potential toxicity of which, in high

doses, is established. Even where preformed vitamin A is concerned, however,

there is virtually, no evidence that daily supplementation with up to 15,000 IUs

will pose any real risk, even in children.@

Hendler, Sheldon Saul M.D., Ph.D. The Doctors= Vitamin and Mineral Encyclopedia.

Simon & Shuster, 1990 (pg 47)

Should Doctors warn pregnant women to avoid carrots, sweet potato, etc?

A carrot contains from 5,000 to 8,000 IU of beta-carotene. A single sweet potato

contains nearly 10,000 IU of beta-carotene. What about apricots, broccoli,

spinach tomatoes and cantaloupe? A cup of dried apricots contains 14,000 IU and

one medium stalk of broccoli can contain 4,500 IU.

5,000 to 25,000 IU beta-carotene safe for pregnant women

A...(for example, one average-sized carrot gives you a full 5,000 IUs of

beta-carotene), and, as a potential preventive against some of the diseases

discussed previously, take a daily supplement of 5,000 to 25,000 IUs of

beta-carotene.. This amount can safely be used by children as well as adults.

Beta-carotene in those quantities is safe for pregnant women too, but, as noted,

all pregnant women should consult with their physicians about any drugs,

vitamins, minerals or other food supplements they, are considering. Pregnant

women should definitely avoid taking more than 5,000 IUs of preformed vitamin A

daily during pregnancy.

Hendler, Sheldon Saul M.D., Ph.D. The Doctors= Vitamin and Mineral Encyclopedia.

Simon & Shuster, 1990

Up to 25,000 IU beta-carotene recommended as beneficial and safe

ABeta-carotene ...has the same results of vitamin A with none of the side

effects. Recommendations are 5,000 IU to 25,000 IU daily in supplemental form.

This dosage, along with some carotenoid-rich foods daily, will aid in

prevention, protect against deficiencies, and promote normal cell functioning.

These doses of beta-carotene are equally safe for children...@

Kirschman & Kirschmann, Nutrition Almanac, 4th Edition, Nutrition Search, Inc.,

McGraw-Hill, 1996.

Daily Recommended Intake during pregnancy is 4,000 IU, and 6500 IU during

lactation.

According to the 1989 Recommended Dietary Allowances, the intake for vitamin A

4,000 IU daily for women, including during pregnancy. During the first 6 months

of lactation, the recommendation increases to 6,500 IU and during the second 6

months of lactation, falls to 6,000 IU.

Vitamin A toxicity is rare, and reversible. Beta carotene not toxic.

ASymptoms disappear quickly when vitamin A toxicity is detected and the vitamin

therapy discontinued. Individual tolerance to vitamin A varies widely among

people. Vitamin A toxicity from dietary sources is rare and is associated

primarily with arctic explorers who consumed excessive amounts of polar bear

liver.

ABeta carotene is not toxic. Large amounts of dark green, yellow, or orange

fruits and vegetables can be consumed over long periods of time with no ill

efects other than a harmless yellowing of the skin, which disappears when fruit

and vegetable intake is reduced.@

Somer, Elizabeth, M.A., R.D. The Essential Guide to Vitamins and Minerals.

Harper Perennial 1992. (Pg 23)

Doctor suggests limit of 10,000 IU vitamin A during pregnancy

AExcess consumption of vitamin A in either supplement form or in cod liver oil

may result in toxicity. Pregnant women should not take over 10,000 IU, and

children should avoid over 18,000 IU. Taking beta carotene cannot result in a

vitamin A overdose.@

Barney, Paul M.D., Doctor=s Guide to Natural Medicine. Woodland Publishing.1998

(pg 33)

Vitamin A important during pregnancy, and a level of not more than 8,000 IU

recommended. Beta carotene not associated with toxicity.

AVitamin A needs during pregnancy are a matter of balance. A severe deficiency

of vitamin A can cause birth defects, while excessive intake might result in

abnormal development of the infant=s nervous system. For this reason daily

vitamin A intake should be limited to no more than 8,000 IU. In contrast, beta

carotene, even in large doses, is not associated with vitamin A toxicity or

birth defects, although there is no reason to consume beyond recommended

amounts.@

Somer, E. M.A., R.D. Nutrition for Women, The Complete Guide. Henry Holt & co.

1993 (pg 163)

Doctor recommends a limit of 10,000 IU vitamin A during pregnancy.

AWhat about pregnancy? ...The only caution is taking too much vitamin A during

the first 3 months. Anything about 10,000 IU may be too much, but this only

applies to preformed vitamin A, not to beta carotene.@

Janson, Michael M.D. The Vitamin Revolution. Arcadia Press, 1996(Pg 140-1)

Most evidence of vitamin A toxicity is based on animal studies; three possible

cases of human toxicity linked to avg of 42,000 IU, 40,000 IU and 150,000 IU

only.

....leads to Amer. Acad. Of Pediatrics recommendation of 6,000 IU upper limit.

APregnancy deserves a very special place in any discussion of vitamin A. This is

a time when you must be cautious about vitamin A supplements, for good

intentions have been known to go haywire, inflicting damage instead.

AMany studies in test animals show that high doses of vitamin A can cause

miscarriages and birth defects. In their report on the safety of vitamin A, the

FASEB scientists cited three children whose birth defects were believed to

result from their mothers' high intakes of vitamin A during pregnancy. The

victims included;

- A baby girl with malformations of the urinary tract, attributed to her

mother's daily consumption of a 25,000 I.U. fish oil supplement during the first

three months of the pregnancy and a still higher daily dose of 50,000 I.U.

during the final six months of her pregnancy.

- A second infant with urinary tract abnormalities, believed to have resulted

from the mother's use of 40,000 I.U. of supplemental vitamin A during the sixth

through tenth week of the pregnancy.

- An infant with abnormalities of the central nervous system, which were linked

to 150,000 I.U. of supplemental vitamin A taken by the mother as an acne

treatment for about three weeks during her pregnancy.

AIn short, the 25,000 I.U. level considered safe for most adults does not apply

during pregnancy. I would urge any pregnant woman to discuss her vitamin A

intake with her obstetrician, who might prescribe a prenatal supplement with

vitamin A. Rest assured that most prenatal vitamins contain only moderate

levels-far less than the amounts associated with the birth defects just

discussed. Depending on your diet, your doctor may feel that no supplement is

needed. Some doctors may prefer to use carotene, which I will discuss shortly,

rather than supplements relying on fish liver oils or synthetic forms, which

have been associated with birth defects when taken in high doses.

AA joint statement of the drug and nutrition committees of the American Academy

of Pediatrics dictates that dosages of vitamin A should not exceed 6,000 IU for

pregnant women.@

Hausman, Patricia M.S., The Right Dose: How to Take Vitamins & Minerals Safely.

Rodale Press. 1987 (pg 38-9)

A limit of 10,000 IU vitamin A during pregnancy recommended by Dr. Balch

AKeep your intake of vitamin A below 10,000 IU daily [during pregnancy]@

Balch, James M.D., Balch, Phyllis, C.N.C. Prescription for Nutritional Healing.

Avery. (Pg 442)

AIt is said that amounts above 8,000 IU may cause birth defects, but I have not

seen any convincing studies to back up this warning.@

AWomen's Health Concerns. Retinol can be one of a woman's most needed nutrients.

Some of premenstrual tension's bothersome symptoms disappear under the vitamin's

influence and may not return even after discontinuing the supplement program. In

one study, 50,000 IU per day reduced heavy menstrual bleeding;14 in other

research, a larger daily amount (150,000 IU) was useful in treating benign

breast disease.15 Taken along with folic, acid and boron, vitamin A contributes

to minimizing hot flashes and other menopausal symptoms.

AIt is not always true that higher doses bring better results. It is said that

amounts above 8,000 IU may cause birth defects, but I have not seen any

convincing studies to back up this warning. Women who are pregnant or who plan

to have a child should consider limiting their A supplementation to no more than

8,000 IU per day unless there is compelling reason to use more. Avoiding the

vitamin completely, however, is not wise. Women need a good supply of it, not

only to make hormones, including progesterone, but to nourish the fetus and

reduce the risk of pregnancy-related complications, such as low birth weight.16

In studies of retinol-deficient mothers-to-be, researchers have found no ill

effects from daily dosages as high as 6,000 IU.17 "

Atkins, Robert M.D. Dr. Atkins= Vita-Nutrient Solution. Simon & Shuster. 1998.

(Pg 46-7)

A...Unlike vitamin A, which can accumulate in tissues and cause toxicity in high

doses, beta carotene is water-soluble and nontoxic, although people who eat a

lot of it, either in natural sources or supplements, may turn orange, a harmless

and reversible, if striking, change in appearance.@

Weil, Andrew. M.D. Eating Well for Optimal Health. Alfred Knoph. 2000. (Pg129)

A safe dose of vitamin A, in pregnancy, is 5,000 IU per day

AA safe dosage of preformed vitamin A for a pregnant woman, or a woman

anticipating pregnancy, is 5,000 IU per day. For the rest of us, signs of

toxicity usually occur only at chronic, daily doses of over 50,000 IU for

adults, or 20,000 IU for children. A dose generally recognized as safe is 10,000

IU per day, though some people with low vitamin A stores in their liver can take

much more without harm.@

Reuben, Carolyn. Antioxidants: Your Complete Guide. Prima Publishing.1995. (Pg

20)

Teratogenicity of high vitamin A intake.

Rothman Kj; Moore LL; Singer MR; Nguyen US; Mannino S; Milunsky A

Evans Department of Medicine, Boston University School of Medicine, MA 02118,

USA.

N Engl J Med 1995 Nov 23;333(21):1369-73

BACKGROUND. Studies in animals indicate that natural forms of vitamin A are

teratogenic. Synthetic retinoids chemically similar to vitamin A cause birth

defects in humans; as in animals, the defects appear to affect tissues derived

from the cranial neural crest.

METHODS. Between October 1984 and June 1987, we identified 22,748 pregnant women

when they underwent screening either by measurement of maternal serum

alpha-fetoprotein or by amniocentesis. Nurse interviewers obtained information

on the women's diet, medications, and illnesses during the first trimester of

pregnancy, as well as information on their family and medical history and

exposure to environmental agents. We obtained information on the outcomes of

pregnancy from the obstetricians who delivered the babies or from the women

themselves. Of the 22,748 women, 339 had babies with birth defects; 121 of these

babies had defects occurring in sites that originated in the cranial neural

crest.

RESULTS. For defects associated with cranial-neural-crest tissue, the ratio of

the prevalence among the babies born to women who consumed more than 15,000 IU

of preformed vitamin A per day from food and supplements to the prevalence among

the babies whose mothers consumed 5000 IU or less per day was 3.5 (95 percent

confidence interval, 1.7 to 7.3). For vitamin A from supplements alone, the

ratio of the prevalence among the babies born to women who consumed more than

10,000 IU per day to that among the babies whose mothers consumed 5000 IU or

less per day was 4.8 (95 percent confidence interval, 2.2 to 10.5). Using a

smoothed regression curve, we found an apparent threshold near 10,000 IU per day

of supplemental vitamin A. The increased frequency of defects was concentrated

among the babies born to women who had consumed high levels of vitamin A before

the seventh week of gestation.

CONCLUSIONS. High dietary intake of preformed vitamin A appears to be

teratogenic. Among the babies born to women who took more than 10,000 IU of

preformed vitamin A per day in the form of supplements, we estimate that about I

infant in 57 had a malformation attributable to the supplement.

Safety of vitamin A: recent results.

Wiegand UW; Hartmann S; Hummler H

F. Hoffmann-La Roche Ltd., Basel, Switzerland.

Int J Vitam Nutr Res 1998;68(6):411-6

A still unresolved public health concern is that excessive vitamin A intake,

like vitamin A deficiency, possibly causes birth defects not only in animals but

also in man. Due to the low incidence of possibly vitamin A-related

malformations in man, available data cannot convincingly define the upper safe

limit of periconceptional vitamin A intake. Direct human intervention studies

are not feasible for ethical reasons. Therefore, a novel approach in addressing

this issue was chosen by combining teratogenicity data from a validated animal

model with data on systemic exposure to vitamin A and its major metabolites in

female volunteers. In a study in pregnant women endogenous plasma concentrations

of vitamin A metabolites during early pregnancy ranged from 0.26 to 7.72 ng/ml.

Since they did not cause any foetal malformations, retinoid plasma levels in

this range can be considered non-teratogenic. Results of a trial in non-pregnant

women document that daily oral vitamin A supplements of

4000, 10,000 and 30,000 IU given for 3 weeks were in the range or slightly

above the range of endogenous plasma levels seen in early pregnancy. Even after

a 3-week treatment with 30,000 IU/day, peak plasma levels of retinoic acid and

isotretinoin were within or just slightly above the range of their physiological

levels. In cynomolgus monkeys (average weight: 3-4 kg), a NOAEL (no observed

adverse effect level) of 7500 IU per kg body weight and a LOAEL (lowest observed

adverse effect level) for developmental toxicity of 20,000 IU/kg was found.

Considering these results in the cynomolgus monkey, a dose of 30,000 IU/day

should also be considered as non-teratogenic in man.

Prevention of congenital abnormalities by vitamin A.

Czeizel AE; Rockenbauer M

Department of Human Genetics and Teratology, National Institute of Public

Health, WHO Collaborating Centre for the Community Control of Hereditary

Diseases, Budapest.

Int J Vitam. Nutr Res 1998;68(4):219-31

The objective of the study was to determine the human teratogenic risk of

vitamin A supplementation during pregnancy. Paired analysis of cases with

congenital abnormalities and matched healthy controls was performed in the large

population-based data set of the Hungarian Case-Control Surveillance of

Congenital Abnormalities, 1980-1994. Of 35,727 pregnant women who had control

infants without defects, 3399 (9.5 %) were treated with vitamin A. Of 20,830

pregnant women who had case offspring with congenital abnormalities, 1642 (7.9%)

were treated with vitamin A, a rate that is significantly lower than that of the

control group (p < 0.001). The case-control pair analysis also showed a lower

rate of vitamin A treatment during pregnancy and in the first trimester of

gestation in most congenital abnormality groups. Thus, use of low or moderate

doses of vitamin A (< 10,000 IU) during the first trimester of pregnancy (i.e.,

organogenesis) is not teratogenic but presents some protective effect

to the fetus.

TITLE: High vitamin A intake in early pregnancy and major malformations: a

multicenter prospective controlled study

AUTHORS: Mastroiacovo P; Mazzone T; Addis A; Elephant E; Carlier P; Vial T;

Garbis H; Robert E; Bonati M; Ornoy A; Finardi A; Schaffer C; Caramelli L;

Rodriguez-Pinilla E; Clementi M

AUTHOR AFFILIATION: Servizio Difetti Congeniti, Policlinico Universitario A.

Gemelli, Rome, Italy. 8682

SOURCE: Teratology 1999 Jan;59(l):7-11

ABSTRACT: The European Network of the Teratology Information Services (ENTIS)

collected and evaluated data on 423 pregnancies exposed during the first 9 weeks

of gestation to a " high " dose of vitamin A (10,000 IU per day or more). Data

were collected prospectively; 394 women (93. 1 %) were followed by telephone

interview up to the first few weeks after the expected date of delivery, using

standardized procedures. The presence of major structural malformations,

excluding chromosomal and genetic diseases, was evaluated in 311 infants exposed

to a median daily dose of vitamin A of 50,000 IU per day (range, 10,000-300,000

1U per day; interquartile range, 25,000-60,000 IU per day). Three infants with a

major malformation were reported: pulmonary stenosis, stenotic anus with

fistula, and bilateral inguinal hernia. No congenital malformations were

reported among 120 infants exposed to more than 50,000 IU per day of vitamin A.

When the birth prevalence rate of major malformations in the

study group was compared with two internal control groups of infants exposed

to: 1) " high " vitamin A exposure later in pregnancy, and 2) nonteratogenic agent

exposures, the rate ratio was, respectively, 0.28 (CI 95% interval, 0.06, 1.23)

and 0.50 (CI 95% interval, 0.14, 1.76). The studied sample did not provide

evidence for an increased risk of major malformations, associated with " high "

vitamin A intake during the organogenetic period, higher than 2.76 above the

control reference risk of 1.91 % (power 80%, alpha 0. 10).

TITLE: Periconceptional vitamin A use: how much is teratogenic?

AUTHORS: Miller RK; Hendrickx AG; Mills JL; Hummler H; Wiegand UW

AUTHOR AFFILIATION: Department of Obstetrics/Gynecology, University of

Rochester, School of Medicine and Dentistry 14642-8668, USA.

SOURCE: Reprod Toxicol 1998 Jan-Feb; 12(l):75-88

ABSTRACT: The objective of the review is to determine whether preformed vitamin

A (retinol and retinyl esters) is teratogenic at dosages commonly used by women

living in industrialized countries. Published human and animal data and research

developed by the authors are reviewed. It is well known that vitamin A is

essential for normal reproduction and development. Although doses of 10,000 IU/d

or less of preformed vitamin A (retinyl esters and retinol) are considered safe,

doses > 10,000 IU/d as supplements have been reported to cause malformations in

a single epidemiologic study. Nonhuman primate data show no teratogenicity at

doses of 30,000 IU/d. Daily periconceptional exposures greater than 25,000 IU/d

of preformed vitamin A have not been sufficiently studied to establish specific

risk. Because no study reports adverse effects of 10,000 IU/d preformed vitamin

A supplements and this dose is more than the Recommended Dietary Allowance for

pregnant women (2670 IU or 800 REM), we

recommend that women living in industrialized countries or who otherwise have

nutritionally adequate diets may not need to ingest more than the Recommended

Dietary Allowance of preformed vitamin A as supplements. If periconceptional

vitamin A exposures to levels up to 30,000 IU/d (9,000 micrograms REM) do occur

unintentionally, multiple animal studies do support only very low risk. Human

epidemiologic studies do not establish at what level vitamin A becomes

teratogenic; however, pharmacokinetic data presented in this paper indicate that

blood levels of retinoids, from women taking 30,000 IU/d of preformed vitamin A

are not greater than retinoid blood levels in pregnant women during the first

trimester who delivered healthy babies. Interestingly, neither teratogenicity

nor vitamin A toxicity has been observed in multiple species exposed to high

doses of beta-carotene.

TITLE: Vitamin A teratogenicity and risk assessment in the macaque retinoid

model

AUTHORS: Hendrickx AG; Peterson P; Hartmann D; Hummler H

AUTHOR AFFILIATION: California Regional Primate Research Center, University of

California, One Shields Avenue, 95616-9542, Davis, CA, USA.

SOURCE: Reprod Toxicol 2000 JulAug; 14(4):311-23

ABSTRACT: Studies were performed in the cynomolgus monkey (Macaca fascicularis)

to provide risk assessment information on safe dose levels of Vitamin A during

human pregnancy. Vitamin A palmitate was orally administered at 7500 IU/kg (2.25

mg/kg) to 80 000 IU/kg (24 mg/kg) body weight during early pregnancy (gestation

day [GD] 16-27). The results indicated a dose-related increase in exposure (AUC)

to retinyl esters and retinoic acids (RA) (all-trans-RA, all-trans-4-oxo-RA,

13-cis-RA, 13-cis-4-oxo-RA). There was also a doserelated increase in abortion

and malformation that affected typical retinoid target tissues in the embryo,

including the craniofacial region, heart, and thymus. The NOAEL and LOAEL for

structural malformations were 7500 IU/kg and 20 000 IU/kg (6 mg/kg),

respectively. A companion study involving oral administration of 13-cis-RA

during the same gestational period established the NOAEL for malformations at

0.5 mg/kg/day, which is close to the human therapeutic dose

range (0.5 to 1.5 mg/kg/day) associated with retinoid embryopathy. Based on the

known similarities in teratogenic susceptibility to 13-cis-RA, the monkey NOAEL

for Vitamin A (7500 IU/kg) was used to estimate safe levels of this nutrient in

humans applying a safety factor of 10. This approach yielded safe levels of

Vitamin A during human pregnancy in the range of approximately 25 000 to 37 000

IU/day.

Notice: The information provided herein is not intended to treat or diagnose

disease, nor is it intended as a substitute for advice provided by your

physician.

Willner Chemists - The Nutritional Supplement Professionals

100 Park Avenue, New York, NY 10017 & 253 Broadway, New York, NY 10007

2900 Peachtree Rd, NE, Atlanta GA 30305

1-800-633-1106 or 1-212-682-2817 or FAX: 1-212-682-6192

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Pregnancy: How much Vitamin A and/or beta-Carotene is appropriate

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