Is Iron-Supplementation Necessary?

By Kelly Bonyata, IBCLC

• Why is anemia uncommon in breastfed babies?
• Which babies are more at risk for iron-deficiency anemia?
• Why not use iron supplements as a protective measure for every baby?
• What are some good iron sources?
• What if my baby’s iron levels have been checked and are TOO LOW?
• In Conclusion
• Additional Information
• References

It’s “common knowledge” that iron supplements are necessary after a baby reaches the magic age of six months. But is this an accurate statement? Let’s look at some of the current research.

Anemia is uncommon in breastfed babies for several reasons

• Healthy, full-term babies have enough iron stores in their bodies to last for at least the first six months. The current research indicates that a baby’s iron stores should last at least six months, depending upon the baby.
• The iron in breastmilk is better absorbed than that from other sources. The vitamin C and high lactose levels in breastmilk aid in iron absorption.
  

  Iron Source	Percentage of Iron Absorbed
  breastmilk	~50 – 70%
  iron-fortified cow milk formula	~3 – 12%
  iron-fortified soy formula	less than 1% – 7%
  iron-fortified cereals	4 – 10%
  cow’s milk	~10%
  Note: The amount of iron absorbed from any food depends greatly upon the milk source of iron (eg, human vs cow), type of iron compound in the food, the body’s need for iron, and the other foods eaten at the same meal.

• Breastfed babies don’t lose iron through their bowels; cow’s milk can irritate the intestinal lining (resulting in a tiny amount of bleeding and the loss of iron).

The original iron stores of a full-term healthy baby, combined
with the better-absorbed iron in breastmilk, are usually enough
to keep baby’s hemoglobin levels within the normal range
the first six months.

Which babies are more at risk for iron-deficiency anemia?

• Babies who were born prematurely, since babies get the majority of their iron stores from their mother during the last trimester of pregnancy.
• In addition, there is evidence that babies whose birth weights are less than 3000 grams – about 6.5 pounds – (whether term or premature) tend to have reduced iron stores at birth and appear to need additional iron earlier.
• Babies born to mothers with poorly controlled diabetes.
• Theoretically, babies born to mothers who were anemic during pregnancy could have lower iron stores, however medical studies do not show this to be a problem. Babies born to mothers who are anemic during pregnancy are no more likely to be iron deficient than those born to mothers who are not anemic during pregnancy.
• Babies who are fed cow’s milk (instead of breastmilk or iron-fortified formula) during the first year of life.

Healthy, full-term infants who are breastfed exclusively for periods of 6-9 months have been shown to maintain normal hemoglobin values and normal iron stores. In one of these studies, done by Pisacane in 1995, the researchers concluded that babies who were exclusively breastfed for 7 months (and were not give iron supplements or iron-fortified cereals) had significantly higher hemoglobin levels at one year than breastfed babies who received solid foods earlier than seven months. The researchers found no cases of anemia within the first year in babies breastfed exclusively for seven months and concluded that breastfeeding exclusively for seven months reduces the risk of anemia.

The original recommendations for iron-fortified foods were based on a formula-fed baby’s need for them and the fact that breastmilk contains less iron than formula (doctors didn’t know then that the iron in breastmilk is absorbed much better). Also, some babies do have lower iron stores and will need extra iron at some point in addition to what they are getting from solids (though this can often be remedied by making sure that solids are high in iron and vitamin C – see below).

If mom or doctor is concerned about a baby’s iron levels, have the doctor to do a blood test for hemoglobin.

Some babies are exclusively breastfed for a year (and occasionally up to two years) with no problems at all.

Why not use iron supplements as a protective measure for every baby?

The iron in breastmilk is bound to proteins which make it available to the baby only, thus preventing potentially harmful bacteria (like E.coli, Salmonella, Clostridium, Bacteroides, Escherichia, Staphylococcus) from using it. These two specialized proteins in breastmilk (lactoferrin and transferrin) pick up and bind iron from baby’s intestinal tract. By binding this iron, they

1. stop harmful bacteria from multiplying by depriving them of the iron they need to live and grow, and
2. ensure that baby (not the bacteria) gets the available iron.

The introduction of iron supplements and iron-fortified foods, particularly during the first six months, reduces the efficiency of baby’s iron absorption. As long as your baby is exclusively breastfed (and receiving no iron supplements or iron-fortified foods), the specialized proteins in breastmilk ensure that baby gets the available iron (instead of “bad” bacteria and such). Iron supplements and iron in other foods is available on a first come, first served basis, and there is a regular “free-for-all” in the baby’s gut over it. The “bad” bacteria thrive on the free iron in the gut. In addition, iron supplements can overwhelm the iron-binding abilities of the proteins in breastmilk, thus making some of the iron from breastmilk (which was previously available to baby only) available to bacteria, also. The result: baby tends to get a lower percentage of the available iron.

Supplemental iron (particularly when administered in solution or as a separate supplement rather than incorporated into a meal) can interfere with zinc absorption. In addition, iron supplements and iron-fortified foods can sometimes cause digestive upsets in babies.

A study (Dewey 2002) found that routine iron supplementation of breastfed babies with normal hemoglobin levels may present risks to the infant, including slower growth (length and head circumference) and increased risk of diarrhea.

A review article on iron (Griffin and Abrams, 2001) indicates that if your baby is basically healthy, iron deficiency in the absence of anemia should not have developmental consequences.

What are some good iron sources?

La Leche League recommends that babies be offered foods that are naturally rich in iron, rather than iron-fortified foods. Read more about when to start solids here: Solid Foods and the Breastfed Baby

Foods that are high in iron include:

• breastmilk
• winter squash
• sweet potatoes
• prune juice
• meat & poultry (beef, beef & chicken liver, turkey, chicken)
• mushrooms
• sea vegetables (arame, dulse), algaes (spirulina), kelp
• greens (spinach, chard, dandelion, beet, nettle, parsley, watercress)
• yellow dock root
• grains (millet, brown rice, amaranth, quinoa, breads with these grains)
• blackstrap molasses (try adding a little to cereal or rice)
• brewer’s yeast

• dried beans (lima, lentils, kidney)
• chili con carne with beans
• tofu
• egg yolks
• grains (cooked cracked wheat, cornmeal, grits, farina, bran, breads with these grains)
• tomato
• dried fruit (figs, apricots, prunes, raisins)
• meat (pork)
• shellfish (clams, oysters, shrimp)
• tuna, sardines

Warning: Some of the foods listed above are not suitable for babies. Dried fruits should not be given to babies under a year old, due to the choking hazard. Also, pork, fish, shellfish, wheat, citrus fruits and eggs are highly allergenic and may not be suitable for babies who are at high risk for allergies. See Suggested ages for introducing allergenic foods for more information.

Iron in the Vegan Diet by Reed Mangels, Ph.D., R.D. also has some great info on iron-rich foods.

See also Iron Content of Common Foods from British Columbia Ministry of Health

You may wish to give baby foods high in vitamin C along with iron-rich foods, since vitamin C increases iron absorption. Cooking in a cast iron pan also increases iron content of foods. The absorption of iron is also increased by eating green leafy salads or citrus fruits, fruit juices and potatoes (including instant potatoes at meals when consuming iron rich foods).

Here’s a combination to try — Cook brown rice (put in the blender if baby needs a smoother texture) and mix it with stewed iron-containing fruits (apricots, prunes, etc). You can even add a touch of blackstrap molasses for extra flavor and extra iron.

The caffeine/tannin in strong tea, coffee, chocolate and cola drinks interferes with the absorption of iron; avoid having these one hour before and one hour after iron rich foods (this note is for adults and children – none of these things are recommended for babies).

What if my baby’s iron levels have been checked and are TOO LOW?

For those babies who do need iron supplementation (hemoglobin levels have been checked and are too low), it’s important to make sure that the solids that baby eats are high in iron and vitamin C. In addition, the combination of yellow dock and dandelion root tinctures are said to be great (and non-constipating) for raising iron levels.

Note: Additional iron intake by the mother will not increase iron levels in breastmilk, even if the mother is anemic. Iron supplements taken by mom may produce constipation in baby. Anemia in the nursing mother has been associated with poor milk supply, however.

One nutritionist I know of has recommended that if this is the first time that you’ve gotten a reading “below normal” (if it is truly below normal – see below) then talk with your doctor about trying FIRST to correct it with diet, then after a few months have a re-test. If it’s still low at that point, then iron supplements may be warranted.

Keep in mind that if your baby has been ill recently, his iron levels may be temporarily low due to the illness (see Hoffman, Ronald, et al. “Chapter 154: Hematologic Manifestations of Childhood Illness : Infectious Disease Changes in Red Blood Cells:  Anemia of Acute Infections.” Hematology: Basic Principles and Practice. Philadelphia, PA: Saunders/Elsevier, 2013.)

Another cause of anemia is lead poisoning – this should be ruled out if your child is anemic. Two of the most common sources of lead exposure in children include (1) paint dust from chipped or peeling lead paint and/or home renovation (may be present in any home built prior to 1978) and (2) lead contaminated drinking water from lead water pipes or lead solder.

A 2003 study by Domellof et al looked at the diagnostic criteria for iron deficiency/iron deficiency anemia in infants, and (from studying 263 exclusively breastfed infants in Honduras and Sweden) determined the following values to suggest the presence of iron deficiency in infants:

Read about how one mother successfully battled anemia in her baby without using iron supplements: Anemia No More.

In Conclusion…

My interpretation of this information is that there is no problem with (and lots of advantages to) continuing with exclusive breastfeeding until your baby is truly ready for solids. At some point toward the end of the first year, your baby will gradually begin to need more iron than that provided by breastmilk alone, so offer your baby foods naturally rich in iron and vitamin C as he begins to eat solids. If there is any question of anemia, get a blood test – if baby’s hemoglobin levels are OK then there is no reason for additional iron in the diet.

Additional Information

Does My Baby Need Vitamins?

Solid Foods and the Breastfed Baby

Why Delay Solids?

Iron Fortified Cereal in Breastfed Infants by Jay Gordon, MD

Do Breastfed Infants Need Extra Iron? by Lauren Milligan Newmark at International Milk Genomics

Breastfeeding and Other Foods (see the section on iron) by Dr. Jack Newman

What to Feed the Baby when the Mother is Working outside the Home by Dr. Jack Newman (solids & iron needs are discussed here, too)

What can I do for my child’s iron deficiency anemia? by Alan Greene, MD, FAAP

Routine Iron Supplementation and Screening for Iron Deficiency Anemia in Pregnant Women from the US Preventive Services Task Force

Anemia in Children by Joseph J. Irwin, M.D. and Jeffrey T. Kirchner, D.O., from Am Fam Physician 2001;64:1379-86.

References

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American Academy of Pediatrics. Committee on Nutrition. Clinical Report—Diagnosis and Prevention of Iron Deficiency and Iron-Deficiency Anemia in Infants and Young Children (0 –3 Years of Age). Pediatrics 2010 Nov;126.

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Griffin IJ, Abrams SA. Iron and breastfeeding. Pediatr Clin North Am (United States), Apr 2001, 48(2) p401-13

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