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Concerns With Early Universal Iron Supplementation of Breastfeeding Infants

  1.  On behalf of the AAP Section on Breastfeeding,
  2. Richard J. Schanler, MD, chair

  1. Department of Pediatrics Cohen Children’s Medical Center of New York at North Shore Manhasset, NY 11030 Department of Pediatrics Hofstra University School of Medicine Hempstead, NY 11549-1000
  1. Executive Commitee,
  2. Lori Feldman-Winter, MD, MPH

  1. Division of Adolescent Medicine Department of Pediatrics Children’s Regional Hospital Cooper University Hospital Camden, NJ 08103 Department of Pediatrics UMDNJ-Robert Wood Johnson Medical School Camden, NJ 08103
  1. Susan Landers, MD

  1. Pediatrix Medical Group Department of Neonatology Seton Medical Center Austin, TX 78705
  1. Lawrence Noble, MD

  1. Department of Pediatrics Mount Sinai School of Medicine New York, NY 10029-6574 Department of Pediatrics Elmhurst Hospital Center Elmhurst, NY 11373
  1. Kinga A. Szucs, MD

  1. Department of Clinical Pediatrics Indiana University School of Medicine Pediatric Primary Care Center Indianapolis, IN 46202
  1. Laura Viehmann, MD

+ Author Affiliations

  1. Clinical Instructor in Pediatrics Warren Alpert Medical School of Brown University Providence, RI 02912

We have major concerns about universal iron supplementation at 4 months in breastfeeding infants, as recommended by Baker, Greer, and the American Academy of Pediatrics (AAP) Committee on Nutrition.1

We point out that as a clinical recommendation for millions of infants, supplementary iron drops beginning at 4 months of age is inconsistent with previous recommendations from the AAP.2,,4.The only supportive data for this recommendation come from a study in which 77 term breastfed newborns were supplemented with iron at some time between 1 and 6 months of age.5 Follow-up studies revealed “improved” psychomotor, but not cognitive, development at 13 months. It has been pointed out that this outcome is unusual and that results of the 13-month examination are not necessarily predictive of overall developmental outcome.6

We would like the authors to acknowledge other ways of ensuring that breastfeeding infants have adequate iron status. We suggest that delayed cord-clamping at birth be included in their recommendations and that screening of “at-risk” infants be used as a guide to determine iron supplementation before the age of 6 months.2,7

The authors did not address potential harms of supplementation, and they did not discuss the difference in bioavailability of iron contained in human milk versus iron-fortified fluids and foods. Given that research has shown potential harm in infant growth and morbidity when iron supplementation is provided to iron-sufficient infants, one wonders if universal iron supplementation will be deleterious to the population of developing infants who are breastfeeding exclusively.8

Furthermore, in a relatively recent US study the prevalence of iron-deficiency anemia was low (3%) among unsupplemented breastfed infants in the first 6 months.9

The authors acknowledged that this report was submitted for review to the AAP Section on Breastfeeding, but they did not mention that we disagreed and provided our additional recommendations 2 years ago. The statement infers that the Section on Breastfeeding, along with many other groups, endorsed this report, which is wrong and will mislead the medical community.

We would welcome a discussion of science and changes in recommendations that are based on available evidence. We do not have an issue with screening at-risk populations. We further request that the “Development of this Report” section be retracted and removed from the published recommendation.


  1. 1.
    1. Baker RD,
    2. Greer FR

    ; American Academy of Pediatrics, Committee on Nutrition. Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0–3 years of age). Pediatrics. 2010;126(5):1040–1050

  2. 2.
    American Academy of Pediatrics, Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2005;115(2):496–506
  3. 3.
    American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Breastfeeding Handbook for Physicians. Elk Grove Village, IL: American Academy of Pediatrics; 2006
  4. 4.
    American Academy of Pediatrics. Pediatric Nutrition Handbook. Elk Grove Village, IL: American Academy of Pediatrics; 2009
  5. 5.
    1. Friel JK,
    2. Aziz A,
    3. Andrews WL,
    4. Harding SV,
    5. Courage ML,
    6. Adams RJ

    . A double-masked, randomized control trial of iron supplementation in early infancy in healthy term breast-fed infants. J Pediatr. 2003;143(5):582–586

  6. 6.
    1. Lozoff B

    . Do breast-fed babies benefit from iron before 6 months? J Pediatr. 2003;143(5):554–556

  7. 7.
    1. Hutton EK,
    2. Hassan ES

    . Late vs early clamping of the umbilical cord in full term neonates: systemic review and meta-analysis. JAMA. 2007;297(11):1241–1252

  8. 8.
    1. Dewey KG,
    2. Domellöf M,
    3. Cohen RJ,
    4. Landa Rivera L,
    5. Hernell O,
    6. Lönnerdal B

    . Iron supplementation affects growth and morbidity of breast-fed infants: results of a randomized trial in Sweden and Honduras. J Nutr. 2002;132(11):3249–3255

  9. 9.
    1. Ziegler EE,
    2. Nelson SE,
    3. Jeter JM

    . Iron supplementation of breastfed infants from an early age. Am J Clin Nutr. 2009;89(2):525–532

Source : AAP


April 20, 2012 - Posted by | Article

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