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.