In November 2010, the AAP issued new age-based recommendations for iron intake in infants and toddlers. Because iron deficiency can have irreversible long-term effects on children’s cognitive and behavioral development, the AAP Committee on Nutrition stated that, “It is critical to children’s health that we improve their iron intake status starting in infancy.”
Babies born healthy at full term are born with sufficient iron stores for the first 4 months of life. Therefore, full-term babies do not need iron supplements prior to four months of age. However, if the infant is breast-fed, the AAP now recommends a 1-mg/kg daily dose of oral iron starting at four months, and continuing until an infant begins eating solid iron-rich foods – typically around six months of age. (Formula-fed infants will receive sufficient iron in their formula and do not need a supplement between four and six months of age.)
There is one caveat: Preterm infants do require iron during the first four months. If they are bottle-fed, the iron-fortified formula will provide the proper amount for these infants. However, according to the AAP, preterm infants who are breast-fed should take a 2-mg/kg daily dose of iron starting at one month of age.
This recommendation has met with some disagreement. The AAP’s Section on Breastfeeding states that no one has “shown a benefit” to iron supplements in breast-fed infants. They also cite a study that showed slower growth among breastfed infants with normal hemoglobin who received iron supplements. Proponents of the new guidelines cite a study that showed the following:
Exclusively breastfed infants supplemented with iron between 1 and 6 months of age had higher hemoglobin concentrations and higher mean corpuscular volume at 6 months of age; and better visual acuity and higher Bayley Psychomotor Development Indices at 13 months of age than did children who did not get supplements.
The new guidelines also urge physicians to screen children at 1 year of age for iron deficiency. (Infants ages 6-12 months require 11 mg of iron a day.) All infants at Willows Pediatrics are screened at this age. There are other points of view to this routinely followed screening recommendation. One group, based in New York, believes that screening is an undue burden and, instead, would like to see a recommendation for iron supplements for all toddlers. Dr. Alvin Eden, chairperson of the Committee on Nutrition for AAP New York Chapter 2, stated that additional blood draws for all 12 month-olds whose hemoglobin is less that 11 g/dL (as the AAP suggests) “puts the pediatrician in a difficult position. What I have been doing is putting all the toddlers on iron supplements for a year after they switch to solid foods.”
The good news is that once children begin consuming solid foods, adequate amounts of iron can be obtained through diet. The AAP recommends early introduction of red meat and vegetables with high iron content. Toddlers ages 1-3 years need 7 mg of iron daily, and the best sources of iron for those children are red meats, iron-rich vegetables, and fruits with Vitamin C. Said Robert Baker, MD, PhD, “Feeding older infants and toddlers foods like meat, shellfish, legumes and iron-rich fruits and vegetables, as well as iron-fortified cereals and fruits rich in Vitamin C, which help iron absorption, can prevent iron deficiency.”
As the debate over the different ways to provide iron supplementation continues, Willows Pediatrics is monitoring your child and will make certain that your infants and toddlers get sufficient iron. At your next check-up, we will gladly discuss this with you and make the appropriate recommendation for your child.