AAP Releases New Guidelines For Preventing Iron Deficiency Anemia

by Melissa Clark Vickers
October 21, 2010

The report is barely out and concerns are already being raised. The American Academy of Pediatrics (AAP) has released a clinical report, Diagnosis and Prevention of Iron Deficiency and Iron-Deficiency Anemia designed to prevent iron deficiency anemia in young children. No one questions the need for adequate iron intake. However, members of the breastfeeding community are questioning the need for universal supplementation of all exclusively breastfed infants with liquid iron starting at 4 months of age and continuing until they are eating iron-rich solid foods.

Why guidelines are needed
Iron is essential for the growth and development of the brain and nervous system. Several studies have identified a link between iron deficiency and irreversible cognitive and behavioral problems. The prevalence of iron deficiency and iron deficiency anemia (IDA) among U.S. children is unclear. According to the AAP report, an estimated 4 percent of 6-month-old infants, 12 percent of 12-month-olds, and between 6.6 and 15.2 percent of toddlers ages 1-3 (depending on ethnicity and socioeconomic status) worldwide are iron deficient.

In order to screen children for IDA, hemoglobin levels are measured using a blood sample obtained through a simple heel or finger stick. Hemoglobin is the iron-rich molecule that makes blood red, and is responsible for transporting oxygen throughout the body. Too little hemoglobin sometimes means too little iron and results in too little oxygen to the cells. However, a low hemoglobin level does not always indicate a low iron level, as there are other conditions, unrelated to iron status that can affect hemoglobin levels.

Although there are alternative tests that can be done to more accurately assess iron levels in babies and infants, they are not universally available, and none are as simple and as inexpensive as a heel or finger stick.

A summary of the AAP recommendations
One of the safest ways to ensure that children (and adults) have adequate iron stores is to include iron-rich foods such as red meats, shellfish, and iron-rich fruits and vegetables in their diets. But for infants who have not been introduced to solid foods, the AAP recommends the following:

• For infants who are exclusively breastfeeding:
  Full-term, healthy babies are born with enough iron stores to last them at least four months. After that, the report recommends supplementing with 1 mg/kg of liquid oral iron daily.

• For infants who are exclusively formula-feeding:
  Provided these infants are consuming iron-fortified formula, no additional supplementation is needed.

• For infants who are mixed feeding:
  For infants over 4 months old who are getting more than 50 percent of their nutrients from breast milk, the report recommends supplementing with the same amount of iron as the exclusively breastfed infant—1 mg/kg per day.

• For infants consuming complementary foods:
  Once a baby is old enough to begin eating solid foods, generally around 6 months of age, the report recommends at least 11 mg of iron a day, preferably from iron-rich foods, and then supplementing with liquid iron as needed.

• For toddlers ages 1-3 years old:
  Toddlers between the ages of 1 and 3 years need 7 mg per day, again, preferably from iron-rich foods, and supplementing as necessary. For example, three ounces of cooked lean beef, a half-cup of cooked spinach, and a half cup of raisins could supply that 7 mg—and might also be more than a toddler would be willing to eat. In addition to the iron-rich foods, toddlers should be encouraged to eat foods high in vitamin C to help absorption. Liquid iron supplements can be given to toddlers from 12 to 36 months, and then chewable multivitamins for children older than 3 years old.

• For preterm babies:
  Preterm infants should have 2 mg/kg per day for 12 months—an amount equivalent to that found in iron-fortified formula. Preterm infants receiving only breast milk need this amount as a liquid supplement until they begin eating complementary iron-rich solid foods, or are weaned to iron-fortified formula.

Unresolved issues
Iron Deficiency Anemia is a serious condition, affecting energy levels, immune response, and brain development—both cognitive and social. This report raises a number of questions, however, especially concerning the breastfed infant.

Human milk contains iron in smaller concentrations than formula. However—and this report fails to mention this—up to 50 percent of the iron in breast milk is absorbed through the intestinal tract into the baby’s body, as opposed to only 4 percent in formula. Breast milk also contains vitamin C and lactose, both of which aid in the absorption of iron.

While it might seem prudent to supplement every child with iron “just in case,” too much iron can lead to slower growth and developmental delays similar to those seen in iron-deficient children. Some studies also link too much iron with increased risk of infection.

There is no indication as to whether the studies used by the AAP to determine iron requirements for infants looked at how the infants were being fed. If the groups of infants that the iron requirements were based on were predominantly formula-fed, then the recommendation could be unnecessarily skewed—much like the growth charts that were based on formula-fed infant growth.

The circumstances surrounding a baby’s birth can impact later iron stores as well. For example, the amount of iron in a newborn’s system can be increased by waiting to cut the umbilical cord until after it has stopped pulsing, an action that transfers more of the mother’s iron-rich blood to the infant. Ensuring that the newborn gets his “full share” of iron-rich blood at birth has been shown to increase the infant’s iron stores, but may also increase the risk for jaundice.

Adequate iron stores along with the iron in human milk will likely ensure that exclusively breastfed babies get all the iron needed until iron-rich solid foods are introduced around 6 months of age.

Should breastfeeding parents supplement with iron?
While these new guidelines issued by the AAP are intended to be universal recommendations, it is important to remember that every baby is different. Parents should discuss their child’s individual situation with his health care provided and decide on the best course of action. At the same time, it’s important to know that some infants are at higher risk for IDA than others including:

• Babies born early or small;
• Babies given cow’s milk before age 12 months;
• Breastfed babies who, after age 6 months, are not fed adequate amounts of iron-rich foods, such as meats or iron fortified cereal;
• Formula-fed babies who do not drink iron-fortified formula;
• Children ages 1–5 years who drink more than 24 ounces of cow, goat, or soy milk per day resulting in an inadequate intake of iron-rich foods, such as meats or iron-fortified cereal; and
• Children who have special health needs, such as children with chronic infections or children on special diets.

The recommendation in this report to begin supplementing a breastfed infant at 4 months of age with iron should not be taken as a recommendation to begin solid foods at that age. Most infants do not show developmental signs of needing solids until at least 6 months, and the benefits of exclusive breastfeeding are not to be dismissed so easily. If you and your doctor determine supplementation is needed, use liquid iron drops—and save any introduction to solid foods for when your baby is truly ready for solid foods.

Editor’s Note—April 26, 2011
“Submitted for review” does not mean “agreed with.” That’s the bottom line in a response from the AAP Section on Breastfeeding to the AAP iron supplementation guidelines released last fall by the AAP Committee on Nutrition.

In a letter published in Pediatrics, Richard J. Schanler, MD, chair of the Section on Breastfeeding, expresses the Section’s concerns about the new guidelines:

• Recommendations are inconsistent with previous recommendations, based on limited and perhaps questionable data.
• There are other ways besides routine supplementation to ensure adequate iron status, including delaying cord-clamping at birth and screening “at-risk” infants.
• Potential risks of supplementation, as well as differences in bioavailability of iron in human milk are not addressed in the guidelines.
• A recent study shows the actual prevalence of iron-deficiency anemia was found in only 3 percent of unsupplemented breastfed infants—the other 97 percent had no problems.

Dr. Schanler also makes it clear that while the Section on Breastfeeding was asked to review the guidelines two years ago and had provided additional recommendations at that time, the Committee’s report fails to mention points of disagreement. He notes that as worded, the Committee’s report implies endorsement by the Section on Breastfeeding, “which is wrong and will mislead the community.”

He goes on to recommend open discussion and removing the “Development of this Report” section from the published guidelines.

This is not the first time that the Section on Breastfeeding and the Committee on Nutrition have disagreed about guidelines for the breastfed baby. The Committee has recommended starting solid foods at four to six months, whereas the Section has recommended exclusive breastfeeding for six months. Publications by either group have cross-referenced the difference.