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Home Nutrition Vitamins/ Supplements Is Iron-Supplementation Necessary?

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 babys iron levels have been checked and are TOO LOW?
In Conclusion
Additional Information
References

Its common knowledge that iron supplements are necessary after a baby reaches the
magic age of six months. But is this an accurate statement? Lets 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 babys iron stores should last at
least six months, depending upon the baby.

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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%

cows 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 bodys
need for iron, and the other foods eaten at the same meal.

Breastfed babies dont lose iron through their bowels; cows 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 babys hemoglobin levels within the normal range
the !rst six months.

Which babies are more at risk for iron- Have you seen
de!ciency anemia? our sponsor
Ardo USA's
Babies who were born prematurely, since babies get the
Calypso breastpump?
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.

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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 cows 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 babys
need for them and the fact that breastmilk contains less iron than formula (doctors didnt
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 babys 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 babys intestinal tract. By binding this

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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 eciency of babys 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 babys 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 (Grin 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 oered 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:

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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)
brewers 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

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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).

Heres 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 caeine/tannin in strong tea, coee, 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 babys 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), its 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 youve 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 its 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 Homan, 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

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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.

Normal iron levels

Hemoglobin [measures iron stores]

concentration Hematocrit (Hct) Serum Ferritin

Age (grams per deciliter) % (micrograms per liter)

newborn 13.5-24 42-68 -not available-

One week 10-20 31-67 -not available-

1-2 months 10-18 28-55 -not available-

2-6 months 9.5-14 28-42 -not available-

10.5-14 33-42 15 is minimum

6-12 months
(12 average) (37 average) (30 average)

1-2 years 11.0-13 32.9-41 (30 average)

2-5 years 11.1-13 34-40 -not available-

Sources:

Centers for Disease Control and Prevention. Recommendations to Prevent and

Control Iron Deficiency in the United States. MMWR 1998;47(No. RR-3).

Hemoglobin, Hematocrit from www.medicinenet.com

Family Practice notebook.com. Hemoglobin.
Nelson Textbook of Pediatrics, 16th edition. Behrman, Kliegman and Arvin; 2000: p. 1462

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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:

Iron Deficiency / Iron Deficiency Anemia in Infants

Hemoglobin Serum Ferritin

concentration (micrograms per liter)
Age (grams per deciliter) [measures iron stores]

4-6 months < 10.5 < 20

6 months <9

9 months < 10.0 <5

Source: Domellof M, Dewey KG, Lonnerdal B, Cohen RJ, Hernell O. The diagnostic criteria

for iron deficiency in infants should be reevaluated. J Nutr. 2002 Dec;132(12):3680-6.

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 oer 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
babys hemoglobin levels are OK then there is no reason for additional iron in the diet.

Additional Information
Does My Baby Need Vitamins?

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Solid Foods and the Breastfed Baby

Why Delay Solids?

Iron Fortified Cereal in Breastfed Infants by Jay Gordon, MD

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 childs iron deficiency anemia? by Alan Greene, MD, FAAP

Anemia and children by Jay Gordon, MD

Routine Iron Supplementation during Pregnancy by John W. Feightner, from The

Canadian Guide to Clinical Preventive Health Care

Screening for Iron Deficiency Anemia Including Iron Prophylaxis from the US Preventive
Services Task Forces Guide to Clinical Preventive Services.

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

References
American Academy of Pediatrics. Committee on Nutrition. Iron fortification of infant
formulas. Pediatrics 1999 Jul;104(1 Pt 1):119-23.

American Academy of Pediatrics. Committee on Nutrition. Clinical ReportDiagnosis and

Prevention of Iron Deficiency and Iron-Deficiency Anemia in Infants and Young Children (0
3 Years of Age). Pediatrics 2010 Nov;126.

Balmer SE, Wharton BA. Diet and faecal flora in the newborn: iron. Arch Dis Child.
1991;66:1390-1394.

Bullen JJ, Rogers HJ, Leigh L. Iron-binding proteins in milk and resistance to Escherichia coli

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infection in infants. Br Med J. 1972;1:69-75.

Bullen JJ. Iron-binding proteins and other factors in milk responsible for resistance to
Escherichia coli.Ciba Found Symp 1976;(42):149-69.

Butte NF, et al. Macro- and trace mineral intakes of exclusively breast-fed infants, Am J
Clin Nutr 45:42-47, 1987.

Centers for Disease Control and Prevention. Recommendations to Prevent and Control
Iron Deficiency in the United States. MMWR 1998;47(No. RR-3).

Dallman PR. Iron deficiency in the weanling: a nutritional problem on the way to resolution.
Acta Paediatr Scand Suppl 1986;323:59-67.

Dewey KG, et al. Iron supplementation aects growth and morbidity of breast-fed infants:
results of a randomized trial in Sweden and Honduras. J Nutr 2002 Nov;132(11):3249-55.

Duncan B. et al.: Iron and the exclusively breastfed infant from birth to six months. J Pediatr
Gastroenterol Nutr 1985;4:421-25.

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

Hamosh M, Dewey KG, Garza C, et al: Nutrition During Lactation. Institute of Medicine,
Washington, DC, National Academy Press, 1991. This book is available free from the HRSA
Information Center (look under Nutrition publications).

Krebs NF. Dietary zinc and iron sources, physical growth and cognitive development of
breastfed infants. J Nutr 2000 Feb;130(2S Suppl):358S-360S.

Krebs NF. Overview of zinc absorption and excretion in the human gastrointestinal tract
[review]. J Nutr 2000 May;130(5S Suppl):1374S-7S.

Lawrence R. Breastfeeding: A Guide for the Medical Profession, 4th ed. St. Louis: Mosby,
1994.

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McMillan JA , Landaw, SA, and Oski, FA. Iron suciency in breast-fed infants and the
availability of iron from human milk, Pediatrics 58:686-92, 1976.

McMillan JA, Oski FA, Lourie G, Tomarelli RM, Landaw SA. Iron absorption from human milk,
simulated human milk, and proprietary formulas. Pediatrics 1977 Dec;60(6):896-900.

Mevissen-Verhage EAE, et al. Eect of iron on neonatal gut flora during the first three
months of life, Eur J Clin Microbiol 4:273-78, 1985.

Mohrbacher N, Stock J. The Breastfeeding Answer Book, Third Revised Edition.

Schaumburg, Illinois: La Leche League International, 2003.

Murray MJ, Murray AB, Murray NJ, Murray MB. The eect of iron status of Nigerien mothers
on that of their infants at birth and 6 months, and on the concentration of Fe in breast milk.
Br J Nutr 1978 May;39(3):627-30.

Newman J. How Breast Milk Protects Newborns.

Oski F and Landau F. Inhibition of iron absorption from human milk by baby food. Am J Dis
Child 1980; 134:459-60.

Pastel RA, Howanitz PJ, and Osk, FA. Iron suciency with prolonged exclusive breast-
feeding in Peruvian infants, Clin Pediatr 20:625-26, 1981.

Pisacane A, et al. Iron status in breast-fed infants. J Pediatr 1995 Sep;127(3):429-31.

Riordan J and Auerbach K. Breastfeeding and Human Lactation, 2nd ed. Boston and
London: Jones and Bartlett, 1999.

Sears W. Pumping Up Your Iron by (also contains a list of iron-rich foods)

Siimes MA, Salmenpera L, Perheentupa J. Exclusive breast-feeding for 9 months: risk of

iron deficiency. J Pediatr 1984 Feb;104(2):196-9.

Stuart-Macadam P and Dettwyler K, ed. Breastfeeding: Biocultural Perspectives, New York:

Walter de Gruyter, Inc., 1995.

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Woodru CW, Latham C, and McDavid S. Iron nutrition in the breast-fed infant, J Pediatr
90:36-38, 1977.

Wootan G. Breastfeeding: New Discoveries

! " #

Updated on May 6, 2017

Filed Under: Vitamins/ Supplements

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