Do exclusively breast-fed infants need supplemental iron?

1. Do exclusively breast-fed infants need supplemental iron? By Ted Greiner, PhD

2. WHO Recommendation, 2001 The evidence from one trial in Honduras demonstrates poorer iron status in infants exclusively breastfed for 6 months, versus 4 months followed by partial breastfeeding to 6 months, and this evidence is likely to apply to populations in which maternal iron status and infant endogenous stores are not optimal.

3. Iron deficiency anemia in Europe • In a study of 11 sites*, prevalence at 12 months was 2.3% • No relationship to breastfeeding • 0% in families with high socio-economic status • Early introduction of cow’s milk was greatest risk factor * Male C et al. Prevalence of iron deficiency in 12-mo-old infants from11 European areas and influence of dietary factors on iron status (Euro-Growth study),Acta Paediatrica 2001;90:492-498

4. Exclusive breast-feeding** Exclusive breast-feeding** for 7 mo (n = 9) for <7 mo (n = 21) Hb concentration, gm/L (SD) 11.7 (0.4) 10.9 (0.7)* No. (%) of Hb concentration <110 gm/L 0 (0) 9 (43) Mean serum ferritin, µg/L (SD) 17 (15) 12.3 (11.7) No. (%) with serum ferritin level <10 µg/L 2 (22) 11 (52) No. (%) with Hb >110 gm/L and serum ferritin level >10 µg/L 7 (78) 10 (48) Hb, Hemoglobin. Pisacane et al, Iron status in breast-fed infants. J.Pediatr 127:429-341, 1995 *t = 3.2; df = 28; p = 0.003. **No other milk or sources of iron Iron status at 12 months

5. Latest review on iron and breastfeeding* • Currently, the best evidence is that [avoidance of iron deficiency] is achieved by • prolonged breastfeeding, • avoidance of unfortified formulas and cow's milk, and • the introduction of iron-fortified and vitamin C-fortified weaning foods at approximately 6 months of age *Griffin, I J; Abrams, S A. Iron and breastfeeding,Pediatric Clinics of North America 2001;48:401-413

6. New Phd by Magnus Domellöf • Iron requirements of term, breast-fed infants. Umeå University, Sweden, 2001 • First reference values for iron for (nearly) exclusively breast-fed babies at 4 vs 6 mon • Only one of five papers published so far

7. Regulation of non-heme iron absorption

9. Effect of iron supplementation on Hb

10. Interpretation • Iron supplementation of iron-replete infants from 6-9 months has no effect • This suggests that at this age iron stores down-regulate absorption • No such mechanism appears to exist before 6 months of age

11. Effect of iron supplementation on iron deficiency anemia

12. Loss in height gain due to iron supplementation

13. Effect of iron supplementation on diarrhea prevalence

14. New suggested cutoffs for infant iron deficiency

15. Impact of 6 months EBF on mother’s iron status* • The additional burden of EBF for 6 compared to 4 months is about 0.5% of body stores • Longer EBF leads to longer amenorrhea, saving iron, especially for women with high menstrual blood loss *Dewey, K G, et al. Effects of exclusive breastfeeding for four versus six months on maternal nutritional status and infant motor development: results of two randomized trials in Honduras.The Journal of Nutrition 2001;131:262-267

16. Conclusions • Breastfeeding exclusively for six months appears to entail no risk of iron deficiency in infants: • Among infants born at term, and • In groups with high socio-economic status, and • When the mother’s iron status is adequate

17. Conclusions (cont.) • Under these conditions, iron supplementation in exclusively breastfed infants under six months of age: • May lead to reduced growth or increased susceptibility to infection, and thus • Should NOT be given routinely, but • ONLY when there is hematological evidence of iron deficiency.