Iron requirements in first 2 y of life

Question 1

What is the assumed iron absorption from human milk, depending on infant’s age and iron status? From infant formulas?

Answer 1

• 20-50% from human milk

- 10-20% from infant formulas

Question 2

Known risk factors for iron deficiency before 2 years of age?

Answer 2

• preterm delivery or birth weight <2500 g
• low socio-economic status
• infants born to mothers with anemia or obesity
• early umbilical cord clamping
• male sex
• exclusive breastfeeding for longer than 6 months
• high cow’s milk intake
• prolonged bottle use
• chronic infection
• lead exposure
• low dietary intake of iron-rich complementary foods

Question 3

Who is particularly vulnerable to iron deficiency? Why?

Answer 3

Infants and toddlers as their needs increase during this period of rapid growth, especially if have low iron stores at birth

Question 4

In what population is the prevalence of IDA up to ten times higher? Why?

Answer 4

• Indigenous communities
• Poverty, food insecurity
• Diminishing access to traditional iron-rich foods and increasing access to low-iron ‘convenience’ foods contribute to reduced iron intake and bioavailability

Question 5

Adverse effects associated with NAID and IDA?

Answer 5

• lower neurodevelopmental scores
• compromised immune response
• toddler’s with IDA have shown lower cognitive and motor function compared with non-anemic controls

Suboptimal neurodevelopment may not be completely reversible with iron supplementation

Question 6

What are iron stores at birth related to?

Answer 6

Birth weight

Question 7

Healthy, term infants of normal birth weight are born with sufficient stores to meet their iron requirements, including hemoglobin synthesis, until when? Then what happens?

Answer 7

• 6 months

- At this point, iron stores become depleted and breast milk alone cannot meet iron requirements beyond 6 months

Question 8

What is the Recommended Dietary Allowance of iron for infants 7-12 months of age? 1-3 years? 4-8 years?

Answer 8

7-12 months: 11mg/day
1-3 years: 7mg/day
4-8 years: 10mg/day

Question 9

What is the recommended amount of iron for the first year for preterm infants born weighing <2000g? Why?

Answer 9

• 2-3mg/kg/day
• LBW infants given iron supplements of 2-3mg/kg/day had slightly higher Hb, improved iron stores, lower risk for developing IDA compared to those who did not receive any supplements

Question 10

What is the recommended amount of iron for the first 6 months for term and preterm infants weighing 2000-2500g?

Answer 10

1-2mg/kg/day

Question 11

What is the timing recommended for starting iron supplementation in LBW infants?

Answer 11

2-3 weeks postnatal age

Question 12

What is the timing recommended for starting iron supplementation for infants in normal weight range?

Answer 12

4 weeks postnatal age

Question 13

Most effective measures to reduce iron deficiency?

Answer 13

• Delayed cord clamping
• If formula feeding, provide iron-fortified formula
• Feed iron-rich complementary foods from age 6 months (e.g. meat, meat alternatives, iron-fortified cereals)
• Delay introduction of cow’s milk until 9-12 months, limit intake to 750ml/day, then to 500ml/day when 1-2years of age

Question 14

Treatment for infants and toddlers deemed to have IDA due to insufficiency iron intake? Dose? How to improve absorption? How long to continue for?

Answer 14

• Oral iron supplements at dosage of 2-6mg/kg/day of elemental iron in divided doses
• Absorption improves when ingested with a source of Vitamin C
• Continue for minimum of 3 months, followed by a reassessment of iron status including CBC and serum ferritin

Question 15

If normal birth weight infants are not breastfed, they should receive formula containing how much iron for the first 9-12 months? What factors would make formula fed infants at higher risk for IDA? How much should their formula have?

Answer 15

-6.5-13mg/L (typical concentration in standard cow’s milk based formulas)

• low SES
• maternal anemia
• low intake of iron-rich complementary foods
• living in indigenous community that may be challenged by poverty, food insecurity
• high consumption of evaporated milk or cow’s milk
• high burden of H. pylori infection
• -> higher iron content of 13mg/L

Question 16

What else can we do for children living in indigenous communities?

Answer 16

Encourage and facilitate access to traditional iron-rich foods

Question 17

What else can be done for populations at higher risk for IDA?

Answer 17

• Case-select infants fo testing to assess benefit of receiving supplementation with oral iron drops before 6 months
• If infant developmentally ready, introduce iron-rich complementary foods between 4-6 months if high risk for IDA

Question 18

What should be done at every well child visit for first 2 years with respect to iron deficiency?

Answer 18

• Assess for risk with particular attention to high-risk individuals (chronic illness, low SES, suboptimal intake of iron rich foods, prolonged bottle feeding)
• Screen with CBC and ferritin appropriately
• When anemia identified, screen further to determine etiology

Question 19

What about toddler formulas for well infants beyond 12 months?

Answer 19

Not necessary. Cow’s milk can be introduced.

Question 20

For which infants is iron supplementation routinely recommended? How much to supplement and for how long if BW 2-2.5kg? How much if BW <2.0kg and for how long?

Answer 20

-Low birth weight infants (<2.5kg) who are predominantly breastfed (>50% of intake)

• 2-2.5kg: 1-2mg/kg/day x 6 months
• <2kg: 2-3mg/kg/day x 1 year of age

Question 21

For low birth weight infants (<2.5kg) who are predominantly formula-fed (>50% of intake), is iron supplementation required?
How much iron does formula provide for infants with birth weight of 2.0-2.5kg?

Answer 21

No, not if formula used is high in iron.

• 2.0-2.5kg: formula provides 1-2mg/kg/day of elemental iron (with formula containing 10-12mg/L of irn)
• <2.0kg: formula provides 2-3mg/kg/day of elemental iron (with formular containing 10mg/L to 14mg/L of iron i.e. formulas specifically designed for prems)