Iron requirements in first 2 years of life

Question 1

* Risk factors for IDA (kids <2yrs):

Answer 1

• low SES
• prolonged bottle use
• chronic infection
• low dietary intake of iron-rich complementary foods
• infant born to mother with anemia or obesity
• BW < 2500 g
• early umbilical cord clamping
• male sex
• exclusive BF > 6 mo
• high cow’s milk intake
• lead exposure

Question 2

What are the 3 different stages of iron deficiency?

Answer 2

• depleted iron stores (low serum ferritin) - non-anemic iron deficiency
• decreased iron transport (low transferrin saturation) - non-anemic iron deficiency
• Iron deficiency anemia (IDA)
  
  • most common micronutrient deficiency worldwide

Question 3

Consequences of iron deficiency in < 2 yrs

Answer 3

• lower neurodevelopmental scores
• compromised immune responses
• lower cognitive & motor function
• may not be completely reversed with iron supplementation

Question 4

ESPGHAN recommendations to reduce iron deficiency

Answer 4

• delayed cord clamping
• iron-fortified formula if formula feeding
• iron rich complementary foods from 6 mo
• don’t use cow’s milk as main milk source until 1 yr old (limit to 500mL/day) —> note that CPS says cow’s milk can be introduced at 9-12 mo max 750mL/day, then offer 500 mL/d of cow’s milk to children 1-2 yrs old

Question 5

Is there evidence that iron-fortified formulas and cereals or iron-rich foods cause adverse GI effect (constipation)?

Answer 5

Little evidence! No

Question 6

Iron requirements at:

7-12 mo

1-3 yr

4-8yrs

Answer 6

7-12 mo: 11 mg/day

1-3 yr: 7 mg/day

4-8 yrs: 10 mg/day

Question 7

How do you treat IDA in kids < 2 yrs?

Answer 7

IDA supplementation:

• infants/toddlers: 2-6 mg/kg/day in divided doses
• improved absorption with vitamin C
• Continue supplements for 3 months followed by CBC/ferritin reassessment

Question 8

When should formula feeding be continued to?

Answer 8

Formula feeding not required beyond 12 mo in healthy infants (cow’s milk can be introduced)

cow’s milk can be introducted at 9-12 mo (limit to 750 mL/day)

Question 9

What is the iron supplement requirement for LBW (<2.5 kg) babies who are breastfed?

Answer 9

LBW (<2.5kg) who are breastfed (>50% intake): iron supplementation routinely recommended - start at 2-3 weeks postnatal age

• BW 2.0-2.5 kg: iron supplement 1-2 mg/kg/day x first 6 mo
• BW <2 kg: iron supplement 2-3 mg/kg/day x first 1 yr

Question 10

What is the iron supplement requirement for LBW (<2.5 kg) babies who are formula fed?

Answer 10

LBW (<2.5kg) who are formula fed (> 50% intake): iron supplementation not required when formula high in iron

• BW 2.0-2.5 kg: formula 10 - 12 mg/L iron provides 1-2 mg/kg/day
• BW <2 kg: formula 10-14 mg/L provides 2-3 mg/kg/day (preterm infant formula)

Question 11

Should you screen healthy infants for IDA?

Answer 11

Insufficient evidence for routine iron supplementation or lab screening in healthy infants with no RF who are exclusively BF for 6 mo

Question 12

Which babies with normal BW should receive higher iron content formula? (13 mg/L)

Answer 12

• formula-fed infants at risk for IDA:
  
  • low SES
  • maternal anemia
  • low intake of iron-rich complementary foods
  • live in Indigenous community with poverty, food insecurity, high consumption of evaporated milk or cow’s milk, high burden H pylori infection
• normal BW infants not breastfed: give formula with 6.5-13 mg/L of iron for first 9-12 months

Question 13

What are your instructions to healthy term infants in order to prevent IDA?

Answer 13

• exclusive BF for first 6 mo of life
• iron rich complementary foods at 6 mo
  
  • traditional foods for Indigenous communities
  • if high risk for IDA, case-selecting infants for testing to assess benefit of iron supplementation before 6 mo
  • consider introducing iron-rich complementary foods at 4-6 mo if developmentally ready and high risk for IDA
• Cow’s milk can be introduced at 9-12 mo (limit 750 mL/day, then offer 500 mL/d of cow’s milk to children 1-2 yrs)

Question 14

How do you screen healthy term infants for IDA?

Answer 14

• Insufficient evidence for routine iron supplementation or lab screening in healthy infants with no RF who are exclusively BF for 6 mo
• Assess for risk of iron deficiency at well child visits in first 2 yrs and screen (CBC, ferritin) appropriately
  
  • particular attention to high-risk:
    
    • chronic illness
    • low SES
    • suboptimal intake of iron rich foods
    • prolonged bottle feeding
  • when anemia identified: screen further to identify etiology

Question 15

What % of body iron is in hemoglobin?

Where else is it stored?

Answer 15

65%

Iron storage

• 65% body iron in hemoglobin
• splenic & hepatic macrophages
• myoglobin
• cytochromes
• ferroproteins

Question 16

What has more iron, breast milk or infant formula?

Answer 16

infant formula contains higher iron levels than human milk

HOWEVER

• human milk: 20-50% absorption
• infant formula: 10-20%