Iron supplementation for babies

Iron supplementation for babies – is it makes sense?

There are many doctors (and parents), that oppose a generalized recommendation for all infants. This is true. It’s also true that there are some populations that are more prone to develop iron deficiency, for whom these recommendations were actually written. However, iron deficiency anemia is the most common deficiency in children (also children that are not part of at-risk populations), and is related to attenuated development and diminished cognitive function in babies.
It is of note that most term babies have iron stores sufficient for the first four to six months of life. After this while, the infant becomes dependent on the iron content of their nutrition and the ability to absorb it from food.
It’s important to emphasize that in this context too, breast feeding is preferable to formula because absorption of iron in breastfeeding babies is higher than in formula fed babies. Starting at age six months (or four months, as you may read on this website), infants’ nutrition should include iron rich foods or food that assists in iron absorption (meat, iron rich grains, legumes, vegetables and fruit).

At what age can iron supplementation be recommended?

In most places, in healthy, full-term babies, the recommendation is to start at the age of four months.

What amount of iron should be given to healthy, full-term babies?

7.5 milligrams (mg) in the first two months (ages 4-6 months), and later 15 mg until the age of eighteen months or until performing a blood count and receiving normal results.

Are there populations of babies in which earlier initiation of iron supplementation is recommended?

Babies born pre-term (before 37 weeks gestation), should receive iron starting at the age on one month, at 3 mg per kilogram of body weight unless recommended otherwise in the hospital discharge letter or by the treating physician. The maximal dose until the age of 6 months is 7.5 mg per day and after that, 15 mg per day.

How much are 7.5 (or 15) mg in drops?

There are many formulations in the market, each formulation is of different concentration. Every formulation should be checked for the amount (usually drops) that will provide the desired dose. Usually, the concentration is of 2.5 mg per drop, thus 3 drops give 7.5 mg.

How should iron be given practically? Where and when?

Parents may decide at what time of the day to give the treatment. But given that routine is important and it’s otherwise easy to forget, it’s wise to prefer a certain time and set-up each day. Because the iron supplement can cause a mess, many parents choose to give the it during bath time.
Again, beside the added bonus of keeping it clean, giving the iron in the same time as part of the same “washing up” ceremony leads to less accidental skipping of the treatment.
It’s very important and not stressed well enough! – Iron will not be absorbed as efficiently in the digestive tract if it is digested together with milk (whether breast-milk or formula). This is because the iron binds to the calcium in milk. That’s why it’s important to separate the administration of iron by at least a half hour from breast-feeding or bottle-feeding. Giving it in at a closer interval will impair the absorbing ability of the baby.
Personally, in our home we used to give the iron in the evening-time, along with the vitamin D that is discussed in another chapter (read more here), in the bath tub (that used to take more than half an hour), after which the babies were fed and put to sleep.

What side effects does iron supplementation have?

In my opinion, if one opens up the internet and reads, there’s no side effect that hasn’t been attributed to these miserable 7.5 mg of iron the baby is trying to receive once a day.
True, iron may cause stomach upset and mild constipation. But many things that have to do with nutrition happen around the age of four months, and attributing the stomach pain and constipation specifically to iron is exaggerated in my view. In case when abdominal pain or constipation are clearly related to iron treatment, it’s possible to temporarily reduce the dose or divide it into twice daily. In cases when the baby does not receive iron for one reason or another, iron rich foods are recommended during the first year of life (or after) – breastfeeding (as opposed to formula), iron rich formulas (every formula sold today has a generous amount of iron), and later iron rich foods as appropriate for age.

Until what age is iron supplementation usually recommended?

Until age one and a half years.

Is it possible to perform a blood test and call off or shorten the duration of treatment?

Yes. It’s possible to perform a complete blood count (usually by finger prick, single test tube) at age 9 months and onwards, to evaluate the iron storages of the baby. In case a blood count was performed, we look at two values: Hemoglobin and Mean Corpuscular Volume (MCV). MCV accounts for the average size of the red blood cell. In cases of iron deficiency, the volume is small and this value is low.

Hemoglobin – a value of less than 11 grams per deciliter indicates anemia.
MCV – a value of 74 and above was determined to be normal in this context. A lower value may indicate iron deficiency, with or without anemia.
The aim of a blood count around the age of one year is only to indirectly evaluate the iron stores and there’s no other medical need to measure the other values.
Besides from the slight discomfort of the needle prick for this test, there’s no reason to avoid it. However, parents should remember they have another option which is to simply continue iron supplementation until the age of 18 months.

So what should be done if the blood count is within normal range?

In these cases, it’s possible to stop treatment with iron at the age of one year. Do note, this is a little confusing, the blood test can be performed starting age of nine months, but even if it is normal the iron is continued until the age of one year. That’s why I recommend whoever plans on performing this test, to aim it closer to the age of one year.

What happens in case when a blood test was performed and anemia or iron deficiency were found?

In these cases, the treating physician should be consulted and several things will be done, including:
• Evaluation with the parents of the compliance and the way in which this primary prevention is given (is it given at all, is it given along with milk which impairs absorption, which foods rich in iron (or not) is the baby eating.
• Thinking if there’s another reason that may be concealed in this baby to cause the abnormal results. There are other medical conditions that may cause anemia or low MCV values (usually thalassemia or chronic disease).
• Recommendation (usually) of the continuation of iron supplementation for a few more months, and later a repeat blood test or additional work-up.

Please also remember that there are differences between health organization and countries. So, learn your specific local recommendation and use this chapter to understand when and how to give iron supplementation for your baby.