Few Hospitals Take Steps Needed to Encourage Breast-Feeding
Posted Aug 05 2011 12:00am
October 14, 2010 — Correction: The original text of this article
described the daily iron dose for infants 6 to 12 months as 11 mg/kg.
This is incorrect. The dose should be 11 mg/day.
October 5, 2010 (San Francisco, California) — Iron deficiency is one
of the most common, yet undetected, problems among children. Here at
the American Academy of Pediatrics (AAP) 2010 National Conference and
Exhibition, the American Association of Pediatrics released a clinical report , with guidelines for iron intake in infants and children and to improve screening methods.
The clinical report, entitled Diagnosis and Prevention of Iron Deficiency and Iron Deficiency Anemia in Infants and Young Children (0–3 Years of Age), was published online October 5 in Pediatrics. It is a revision of a 1999 policy statement.
Iron deficiency can have long-term irreversible effects on a child's
cognitive and behavioral development. By the time a child develops
iron-deficiency anemia, it might be too late to prevent future
problems. "The body has a preferential tracking of iron. Red blood
cells take precedence over the iron requirements of the brain. By the
time you get iron-deficiency anemia, you've been iron-deficient for a
long time," said Frank Greer, MD, professor of pediatrics at the
University of Wisconsin School of Medicine and Public Health in
Madison, and a coauthor of the report.
The 1999 guidelines call for children to have their hemoglobin
checked sometime between 9 and 12 months of age, and again between 15
and 18 months of age. However, the existing test misses many children
with iron deficiency and iron-deficiency anemia. Even those found to
be iron deficient frequently receive no follow-up testing or
treatment, according to Dr. Greer.
Although supplementing all children with iron would reduce iron
deficiency, such a program does not have widespread support in the
medical community at this point. That's partly because toddlers, who
are the most widely affected group, have a wide range of diets and it
is unclear what foods to fortify.
Liquid iron supplements or vitamins could be used, but there is a
risk for iron overload in some populations, according to Michael K.
Georgieff, MD, professor of pediatrics and child psychology and
director of the Center for Neurobehavioral Development at the
University of Minnesota in Minneapolis. Dr. Georgieff was on the AAP's
committee on nutrition from 1993 to 1999 and played a key role in the
"Iron supplementation and awareness of iron nutrition has probably
been one of the most successful public health programs in the United
States. In the 1960s, iron deficiency was probably 30% to 40%. Today,
it may be under 10%. But in trying to eliminate that last 10%, you
have to consider it in terms of exposing kids to [too much] iron,"
said Dr. Georgieff.
No single screening test is available that will accurately
characterize the iron status of a child, he noted. In the report, the
AAP recommends 4 protocols for screening for iron deficiency and
iron-deficiency anemia, including combinations of several tests and
follow-up protocols. "It's burdensome," Dr. Greer admitted.
"Since we're not going to do universal supplementation, we need to
identify kids who are at risk for iron deficiency and start targeting
them," said Dr. Georgieff, who studies the neurodevelopmental effects
of iron deficiency in children.
The AAP report identified several factors associated with iron
deficiency and iron-deficiency anemia, including prematurity or low
birth-weight, lead exposure, exclusive breastfeeding past 4 months of
age without iron supplements, and weaning to foods that don't include
iron-fortified cereals or iron-rich foods. Infants with special
healthcare needs might also be at risk. Children of low economic status,
particularly those of Mexican American descent, are also of concern,
according to the report, which recommends selective screening for
The guidelines also address means to prevent iron deficiency through a
diet of foods naturally rich in iron, such as meat, shellfish,
legumes, iron-rich fruits and vegetables, and iron-fortified cereals.
Fruits rich in vitamin C help iron absorption. Some children might
require liquid iron supplements or chewable vitamins to get sufficient
The AAP recommends varying amounts of iron based on a child's age
Term, healthy infants have sufficient iron
for the first 4 months of life. Because human breast milk contains
very little iron, breastfed infants should be supplemented with
1 mg/kg per day of oral iron from 4 months of age until iron-rich
foods (such as iron-fortified cereals) are introduced.
Formula-fed infants will receive adequate
iron from formula and complementary foods. Whole milk should not be
used before 12 months.
Infants 6 to 12 months of age need 11 mg/day
of iron a day. When infants are given complementary foods, red meat
and vegetables with high iron content should be introduced early.
Liquid iron supplements can be used if iron needs are not met by
formula and complementary foods.
Toddlers 1 to 3 years of age need 7 mg per
day of iron. It is best if this comes from foods such as red meats,
iron-rich vegetables, and fruits with vitamin C, which enhance iron
absorption. Liquid supplements and chewable multivitamins can also be
All preterm infants should have at least
2 mg/kg of iron per day until 12 months of age, which is the amount of
iron in iron-fortified formulas. Preterm infants fed human milk
should receive an iron supplement of 2 mg/kg per day by 1 month of
age; this should be continued until the infant is weaned to
iron-fortified formula or begins eating foods that supply the required
2 mg/kg of iron.
American Academy of Pediatrics (AAP) 2010 National Conference and Exhibition. Presented October 5, 2010.