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Do Breastfeeding Babies Need Extra Iron at 4 Months?

Susan Burger, MHS, PhD, IBCLC, my guest poster today, maintains a private lactation practice in New York City.  She is one of my favorite scribes on Lactnet, our professional listserv.  Her doctorate in nutrition and her work with breastfeeding mothers and babies in developing areas of the world add weight to her insights into this controversial topic . 

Should exclusively breastfed babies be routinely supplemented with extra iron?  Yes, according to the Committee on Nutrition of the American Academy of Pediatrics (AAP) in its recently issued Clinical Report.  It justifies this recommendation by citing its “concerns that iron deficiency anemia and iron deficiency without anemia can have long-lasting detrimental effects on neurodevelopment.”  

As a mother myself and as someone who worked for many years on large-scale public health nutrition programs for mothers and children in developing areas, I certainly want the AAP to fully investigate and make solid recommendations about the potential impact of iron deficiency on cognitive development. 

In the late 1980s when I did my doctoral studies in nutritional sciences at Cornell, it was common knowledge that much of the iron that is stored by the fetus occurs in the last trimester of pregnancy. The closer to 40 weeks of gestation, the better the iron stores at birth.  More recent evidence has been accumulating that clamping the umbilical cord sooner than 2 minutes after delivery may deprive infants of a last and relatively substantial contribution of iron from the placenta to the newborn’s iron stores. 

Over 20 years ago, we knew that the iron in human milk is easily absorbed and that the iron added to formula is not and that extra iron may even interfere with absorption of iron from mother’s milk.  From the evidence at that time, we generally accepted that healthy full-term babies did not need additional sources of iron until they were around 6 months old.  In fact, a 2009 study reinforces this assumption.  The prevalence of iron deficiency was only 3% among otherwise exclusively breastfed infants who were randomly assigned to receive a placebo between 1 and 6 months of age.

So, I was expecting the AAP Committee on Nutrition to recommend ways to reduce preterm deliveries and premature cord-clamping and to remove barriers to exclusive breastfeeding for the first 6 months. Instead, the Committee’s ONLY recommendation was to start supplementing term breastfed infants with iron at 4 months. 

In puzzlement, I thought perhaps the Committee was privy to some new information of which I was unaware.  So, I carefully read the rationale for the recommendation and was surprised to see that it cited one study.  Again puzzled, I thought perhaps this one study was so astoundingly thorough that it upended all the other evidence I had read.  So, I read its methods section carefully. 

My expectations were dashed.  The sample size was small; only 77 babies were randomly assigned to receive either an iron supplement or a placebo at the start of the study. The drop out rate was high; 43% of the infants had dropped out by the time that developmental tests were administered at 13 months of age.  Compliance was low; study babies received the iron or placebo only 56% of the time they were supposed to receive these.

Furthermore, the study subjects do not match the population considered by the AAP Committee on Nutrition. The study babies were not “exclusively breastfed” as mentioned by the Committee; the researchers classified these babies as “breastfed” even though a few were given up to a bottle of formula a day from the start of the study and most were drinking formula by 6 months of age. The study babies did not start iron supplementation at 4 months as recommended by the Committee; the researchers started iron supplements or placebos at 1 month of age and continued for another 5 months.  So we really don’t know if the results would hold up among a group of infants who were started on iron supplement at 4 months of age and otherwise receiving nothing but mother’s milk until 6 months of age.

Finally, the sample size was not nearly sufficient to evaluate some of the potential harmful effects of iron supplementation among babies with healthy iron levels that were found in other studies, such as increased risks of infection and slower linear growth.

To the authors’ credit, they did not extrapolate beyond the findings of their own study when they wrote that a “larger study that focuses on the long-term developmental outcomes is needed before recommendations can be considered regarding the whole population of breastfed infants.”  Yet, the Committee went ahead and made a blanket recommendation anyway. 

I thought perhaps I was alone in my thinking when I read the long list of committees and groups cited as contributing to the report.  Then, I looked at the e-letters responses and discovered that others actually had similar objections, including the Chairperson of the AAP Section on Breastfeeding, Dr. Richard Schanler who stated:

 “…. the authors acknowledge that this report was submitted for review to the Section on Breastfeeding of the [AAP]. It did not mention that we disagreed and provided our additional recommendations, 2 years ago. The manuscript infers that the Section, along with many other groups, endorsed this report. This is wrong and will mislead the medical community.  We would welcome a discussion of science and changes in recommendations that are evidence-based.  We do not have issues with screening at-risk populations. We further request that the section “Development of this Report,” be retracted and removed from publication.”

I agree with Dr. Schanler that a discussion of the science is important. In the meantime, I have far more confidence in the previous recommendations of the American Academy of Pediatrics that iron supplements should not be routine for exclusively breastfed babies before 6 months of age.  As solids are introduced, selecting an appropriate mix of foods that include those rich in iron may circumvent any need to use supplements even after 6 months of age.


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Reader Comments (14)

my son is 10 months and they had him do the blood draw because he is exclusively breastfed. it was awful for him and I, and it turns out his iron levels are wonderful! i give him extremely well-rounded meals and he nurses quite often.

November 29, 2010 | Unregistered CommenterLeeta-Rose

Citing a study with an initial cohort size of 77 (some participants dropped out) is unconsionable. Who paid for the study in the first place?

November 29, 2010 | Unregistered CommenterHelen

Wow. Makes you wonder who is profiting from this. Sad but true, profits seem to come before people when it comes to research. It does seem to benefit the formula companies to have misinformation spread about breastfeeding babies not getting everything they need from breastmilk.

So have there been any long term studies done on the effects of giving babies iron supplements from the tender age of 4 months? The less we interfere with nature the better. I wholeheartedly agree with the attitude that we should be looking at ways to decrease pre-term deliveries and delay cord clamping (two things I did for my daughter - without even realising the full benefits at the time). But then where are the profits in that?

November 29, 2010 | Unregistered CommenterAnna

Susan's posts and comments are always well thought out and insightful. Her views on the iron supplementation policy is no different! Thank you for sharing Susan's writings on this hot topic. In private practice it is a topic many of my clients have questions about.

November 30, 2010 | Unregistered CommenterMelissa Cole

Yet another misleading guideline to undermine breastfeeding. Thank you for delving into the research and bringing this information to light. I'd like to see this as a press release, rewritten to emphasize how wrong the guideline and study are-- in the very first paragraph - so that reporters and readers skimming the article don't get the wrong impression.

November 30, 2010 | Unregistered CommenterBetsy Hoffmeister, IBCLC

I'd like to read some more information about the absorption rates of iron from breastmilk, iron from whole foods, and iron supplements. At my son's 9mo checkup his iron levels tested slightly low (10.2, Dr wanted 11 or above), and his Dr started pushing supplementation. He's exclusively breastfed and we had just started introducing solid foods at that point, so I questioned her about the bio-availability of iron in my milk versus in a fortified cereal or supplement. She essentially blew off my question and continued to push for supplementation. I have opted to ignore her advice, and instead have been feeding my son a variety of iron-rich foods (lots of quinoa and dark greens). At almost 11mos now, I need to have his levels retested, but would like to have some literature to bring with me backing up my decisions when I do so.

November 30, 2010 | Unregistered CommenterDelora

Thank you, thank you for this! I will share with both my pediatrician and the readers of my blog.

November 30, 2010 | Unregistered Commentertanya@motherwearblog

Hi Delora. I hope you don't mind if I seek to comment on your great question. Of course the bioavailability in your milk is greater than in fortified cereal or a supplement. The issue is not a question of breastmilk "versus" fortified cereals or supplements. The issue is when do infants start needing more iron than they can absorb from mother's milk. This is because the iron stored in the last trimester of pregnancy doesn't last forever and because the overall concentration of iron in mother's milk is low. There are various theories why it is low and how this may be protective in the first six months of life.

In terms of what happens after six months, the research on the need for additional iron is much stronger than the research I critiqued about iron supplements before six months of age. Correspondingly, the prevalence of iron deficiency does increase between six and nine months of age among US infants. Furthermore, the research that iron deficiency after six months of age may have a detrimental and permanent impact on cognitive development is also stronger. For these reasons, it is usually recommended to include iron-rich foods into the diet when foods are introduced to "complement" mother's milk at around six months of age.

Since your son's hemoglobin levels were low, this means that he very well could have been anemic at nine months of age. Anemia is an outcome of iron deficiency. So, it is plausible that your son was also deficient in iron. It could be the foods you started to introduce at nine months of age may have improved your son's iron status. Given the importance of iron for cognitive development, I would definitely have this checked. If you find that his hemoglobin levels continue to be low, I would considered adding foods that are richer in iron. The iron from many vegetable sources is less bioavailable than iron from meats. So, if you are vegetarian and are finding it challenging to boost his iron levels, there may be a role for considering iron-fortified cereals or iron supplements.

December 2, 2010 | Unregistered CommenterSusan Burger

I have many friends who have done cord blood storage/donation which I have chosen not to do due to the super-quick clamping of the cord needed, which earlier research indicated negatively affects both blood iron and jaundice levels in the newborn...

also, since formula supplementation can cause irritation of the intestinal lining and blood/iron loss in the newborn, any study that does not eliminate this source of "iron loss" in the newborn would be other words, an exclusively breastfed child keeps iron levels higher than a "combination-fed" baby but I am sure this would make the study size even smaller!

December 2, 2010 | Unregistered CommenterCarla

We didn't do anything special for my daughter who was born on her due date a healthy 8lbs. 6oz...and then for some reason I didn't think to do anything other than breastfeed my son who was born at 38 weeks weighing in at only 4lbs. 10oz. Sadly by the time he was 9 months old he was very anemic and should have had some kind of supplement...but he wasn't tolerating solids very well and I just assumed in time he would. He then refused all types of iron we could get into him and eventually we got his levels to come up cooking with caste iron, feeding him high iron foods paired with foods rich in vitamin C and time...meatballs and sauce, green veggies, sweet potato with black strap molasses. The amazing thing that happened with his levels coming up were the improvements in his health...this poor little guy who was so sick with every cold was all of a sudden handling colds with little to no problem and we didn't have to give him his nebulizer anymore and he stopped needing his prevacid for reflux as well.

December 3, 2010 | Unregistered CommenterKate

Kate's son is a perfect example of why looking for sources of iron-rich solids is important around six months of age and why some babies need additional earlier. His birth weight and gestational age put him at higher risk. And for babies that cannot consume enough iron via foods, supplements are very helpful. Her example is an appropriate use of supplements. An APPROPRIATE level of iron is very important. I'm glad that Kate found a solution for her little guy and that he's doing better.

December 4, 2010 | Unregistered CommenterSusan Burger

This is why I always encourage our LLL moms to consider organic chicken livers as one of the earliest foods they feed their little ones. The texture is so soft that even a new eater can handle it (my daughter was eating pieces of it by a little past 7 months), it's high in iron and vitamin D as well. Other meats are also well tolerated. I think that what doctors never seem to tell moms is that iron isn't well absorbed except in the presence of vitamin C or a meat factor. Babies generally love liver because no one has told them yet that it's icky. It's the moms who have a hard time with the idea of even cooking it. Of course egg yolks are another option, but only if you're giving some vitamin C food at the same time.

December 19, 2010 | Unregistered CommenterLiz

My son is 12 months old. He had his first finger prick at WIC last week. His iron level was 8. He comes from a family history of iron deficiency anemia, anemia and thalassemia minor. My father, my sister and myself all have thalassemia minor. Because his reading was so low, I called my pediatrician. She ordered a "venipuncture"... The results from the thalassemia test have not come in yet, but because his red blood cells and iron are low (9.5 on the blood draw) she wants him to start an iron supplement. 
     After speaking with my LC, my desire to avoid artificial iron unless necessary was reassured. We talked about using iron rich foods paired with foods high in vitamin C in his diet until his test results come in. He has been exclusively breastfed and eats some solids.
         My questions are: what recommendations can you make for this type of situation? How low is too low for an iron level? What are the longterm effects of low iron on a child? Could his low iron be why he has battled recurrent colds since fall and 2 ear infections? Does cooking with cast iron really help? Are there any good resources/cookbooks out there for cooking for those with low iron? My 3.5 and 5 year old daughters have low iron (not as low as the baby) readings at WIC, too... How important is it that they be tested for thalassemia/anemia? Would my children benefit from seeing a nutritionist and/or hematologist? 

Thank you so much for any advice you can give!

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