Iron Supplementation Guidance for Infants

Posted by Pankaj Arora @pankajarora, Sun, May 26 1:32pm

Hi folks,

The American Academy of Pediatrics' official guidance essentially states all exclusively (or primarily) breastfed infants should receive iron supplementation at four months of age (at 1 mg/kg/day dosage). The guidance of universal supplementation is widely-cited by countless healthcare sources, particularly American ones, including the Mayo Clinic's own website.

However, there appears to be unsettled controversy, confusion, and disagreement with these guidelines. For example, the WHO, Canadian Pediatric Society, and every Pediatrician I've spoken with does not suggest universal supplementation at four months. In fact, in April 2011, a letter to the an AAP Journal editor, sent on behalf of the AAP Section on Breastfeeding, was published citing "major concerns" about the guidance of universal supplementation – highlighting the fact that there is disagreement within their very own organizational members. There are several websites, albeit generally not ones of major American medical institutions, that seem to credibly discuss the potential hazards of this guidance and the flaws in the original small-scale study that was the basis of this recommendation. There is even at least one study that seems to indicate universal supplementation at that age might be more detrimental than helpful overall.

I understand every infant is different – and factors such as low birth weight, premature delivery, and even gestational diabetes can have an impact on iron stores. The vast majority of an infant's store is accumulated in the last trimester. Perhaps the safest guidance is "consult with your Pediatrician." Yet, I imagine viewpoints vary – and I have both a point of discussion and concern:

1. I would love to gather more information on how other healthcare professionals think about and make this decision of whether to supplement at four months or not, and learn about the various viewpoints that may exist. I would love to hear from this community on this topic.

2. I am concerned that by not clarifying, revisiting, or outright changing the AAP guidance provided, a disservice is being done to the community at large. While this issue has been seemingly left unaddressed for nearly a decade – the importance of the matter remains, along with the confusion it has caused for what I can only imagine is countless healthcare professionals and parents who encounter conflicting guidance. At worst, it seems possible that this guidance could be detrimental to some. It is amplified by the fact that it is widely-quoted. To that end, I have reached out to the AAP highlighting the concern and requesting further clarification on this matter.

Appreciate any thoughts and insights. My intent is one of a good faith effort to promote the publication of better, clearer, and hopefully less controversial guidance on this matter, as I believe that would be in everybody's best interest. Again, I would love to hear from this community on how folks approach and think about this potentially consequential decision.

Thanks,
Pankaj

Hi @pankajarora and welcome to Connect!

You bring up some great thoughts and ideas about iron supplementation guidance for infants. What first interested you in this subject? Was it personal experience?

REPLY
@ethanmcconkey

Hi @pankajarora and welcome to Connect!

You bring up some great thoughts and ideas about iron supplementation guidance for infants. What first interested you in this subject? Was it personal experience?

Jump to this post

Hi @ethanmcconkey, thanks for the warm welcome!

We have an infant that is between 4-5 months of age, so we ourselves are trying to figure out the right path on this matter. Currently, we are following our Pediatrician's advice and ignoring the AAP guidance. But it's a bit unsettling to see contradicting advice from otherwise credible sources — especially ignoring the guidelines of a body such as the AAP. We'd love more clarity/perspective soon on this for our own interests, yet also know it would be beneficial to many others given the lack of consensus and confusion I'm sure other parents and even healthcare professionals have faced on this topic.

REPLY

@pankajarora
I believe the AAP guidelines refer to full term, healthy infants. For exclusively breastfed infants iron supplementation should start at 4 months and continue until solid foods that are iron fortified are started after 6 months of age. The infant is born with an iron store from the mother lasting about 4 months. Formula fed infants can be fed formula with iron.
Premature infants don’t have much of iron store and need supplement from the start.

REPLY
@astaingegerdm

@pankajarora
I believe the AAP guidelines refer to full term, healthy infants. For exclusively breastfed infants iron supplementation should start at 4 months and continue until solid foods that are iron fortified are started after 6 months of age. The infant is born with an iron store from the mother lasting about 4 months. Formula fed infants can be fed formula with iron.
Premature infants don’t have much of iron store and need supplement from the start.

Jump to this post

Thanks for your response. You are correct, that is the AAP guidelines. However, the WHO, Canadian Pediatric Society, and many Pediatricians say don't bother at four months for full term healthy BF infants. There seems to be more consensus around six months and utilizing solid foods (incl fortified ones) where possible.

It is also disputed within the AAP as well. Here's a good summary article: <Search for "Experts Challenge AAP Iron Supplement Policy"> and here's the AAP editor letter that originally challenged the guidance: <Search for "Concerns With Early Universal Iron Supplementation of Breastfeeding Infants"> (I would have posted direct links but apparently new members can't do that). There are also some sources online that seem to imply universal supplementation at four months could even be detrimental.

Again you are correct in reciting the AAP guidance, which confusingly our Pediatrician, and a few others we spoke to, suggested we don't adhere by – which is at the root of our concern on this matter for us and other parents given the conflicting advice.

REPLY

@pankajarora – I agree that it is confusing. However, Pediatricians know their patients’ general health and other concerns so it makes sense that that they can make appropriate recommendations for each patient. Also, many infants start iron fortified cereal at 4 months, depending on rate of growth and milk supply. Iron can cause stomach upset and constipation too. There are times when iron supplement is given if infant has an ongoing illness.

REPLY
@pankajarora

Thanks for your response. You are correct, that is the AAP guidelines. However, the WHO, Canadian Pediatric Society, and many Pediatricians say don't bother at four months for full term healthy BF infants. There seems to be more consensus around six months and utilizing solid foods (incl fortified ones) where possible.

It is also disputed within the AAP as well. Here's a good summary article: <Search for "Experts Challenge AAP Iron Supplement Policy"> and here's the AAP editor letter that originally challenged the guidance: <Search for "Concerns With Early Universal Iron Supplementation of Breastfeeding Infants"> (I would have posted direct links but apparently new members can't do that). There are also some sources online that seem to imply universal supplementation at four months could even be detrimental.

Again you are correct in reciting the AAP guidance, which confusingly our Pediatrician, and a few others we spoke to, suggested we don't adhere by – which is at the root of our concern on this matter for us and other parents given the conflicting advice.

Jump to this post

Hi @pankajarora and welcome to Connect.
I got a notice that you wanted to share a link with information. You will be able to add URLs in a few days. There is a brief period where new members can't post links. We do this to deter spammers and keep the community safe. Clearly the links you wanted to post were not spam. Please allow me to post it for you.

– Experts Challenge AAP Iron Supplement Policy (2010) https://www.mdedge.com/pediatrics/article/40318/health-policy/experts-challenge-aap-iron-supplement-policy
– Concerns With Early Universal Iron Supplementation of Breastfeeding Infants (2011) https://pediatrics.aappublications.org/content/127/4/e1097

REPLY
@colleenyoung

Hi @pankajarora and welcome to Connect.
I got a notice that you wanted to share a link with information. You will be able to add URLs in a few days. There is a brief period where new members can't post links. We do this to deter spammers and keep the community safe. Clearly the links you wanted to post were not spam. Please allow me to post it for you.

– Experts Challenge AAP Iron Supplement Policy (2010) https://www.mdedge.com/pediatrics/article/40318/health-policy/experts-challenge-aap-iron-supplement-policy
– Concerns With Early Universal Iron Supplementation of Breastfeeding Infants (2011) https://pediatrics.aappublications.org/content/127/4/e1097

Jump to this post

Makes sense, and thank you!

REPLY

Thank you @colleenyoung for sharing those links and @astaingegerdm for continuing the conversation. I also wanted to share that Pediatrician Dr. Angela Mattke hosts a live video Q&A on a specific topic with a guest the first Thursday of the month. The next session will be on June 6 at 11am CDT.

Video Q&A about Preparing Your Child for Medical Procedures https://connect.mayoclinic.org/webinar/video-qa-about-preparing-your-child-for-medical-procedures/

I also wanted to share this article by Mayo experts on iron deficiency in children:
– Iron deficiency in children: Prevention tips for parents https://www.mayoclinic.org/healthy-lifestyle/childrens-health/in-depth/iron-deficiency/art-20045634

REPLY
Please login or register to post a reply.