The new American Academy of Pediatrics guidelines for iron supplementation are drawing criticism from experts who say they go too far – and others who say they don’t go far enough.
"I’m not aware of any movement afoot in the obstetrics community to prolong the time before cord clamping" as an alternative to iron supplementation, said Dr. E. Albert Reece, the John Z. and Akiko K. Bowers Distinguished Professor and dean of the School of Medicine at the University of Maryland, Baltimore.
The AAP’s Section on Breastfeeding wants to strike the recommendation that all breastfed children should get iron supplements. "No one has shown any benefit to doing that," said section chairperson, Dr. Richard J. Schanler, professor of pediatrics at Albert Einstein College of Medicine, N.Y.
By contrast, the AAP’s local nutrition committee for a New York chapter would like to see a recommendation of iron supplements for all toddlers.
The guidelines "Diagnosis and Prevention of Iron Deficiency and Iron-Deficiency Anemia in Infants and Young Children (0-3 Years of Age)," were published in November (Pediatrics 2010;126:1040-50), after the AAP’s Committee on Nutrition spent 5 years soliciting comments from a wide range of sources, including the Section on Breastfeeding, said Dr. Frank R. Greer, an author of the guidelines.
"It’s not without controversy," said Dr. Greer, professor of pediatrics at the University of Wisconsin, Madison. But he argued that the guidelines offer the most practical course for pediatricians advising parents of young children.
The debate over exclusively breastfed infants focuses on 2 months – the interval between 4 and 6 months of age. "Term, healthy infants have sufficient iron for at least the first 4 months of life," the guidelines state. "Human milk contains very little iron. Exclusively breastfed infants are at increasing risk of ID [iron deficiency] after 4 completed months of age." They call for 1 mg/kg per day of oral iron supplements beginning at 4 months of age until the babies begin eating iron-containing foods.
The AAP already recommends that complementary foods containing iron be introduced after 6 months. So the question is whether exclusively breastfed babies should get oral iron drops for the last 2 months before beginning to eat solid foods.
The guidelines acknowledge that the prevalence of iron deficiency among children under 12 months of age in the United States is unknown. But the document cites a double-blind controlled trial showing benefits (J. Pediatr. 2003;143:582-6). Exclusively breastfed infants supplemented with iron between 1 and 6 months of age had higher hemoglobin concentration and higher mean corpuscular volume at 6 months of age; and better visual acuity and higher Bayley Psychomotor Developmental Indices at 13 months, than did children who did not get supplements.
At the very least, supplementing with iron does no harm, argues Dr. Greer. "All the formula-fed babies get iron in their formula," he said. "Where is the harm to those babies?"
But Dr. Schanler argued that at least one study has found potential risk (J. Nutr. 2002; 132:3249-55). This controlled trial found slower growth among breastfed infants with normal hemoglobin who received iron supplements than those who did not receive supplements.
The two studies, one showing benefits and one showing detriments, are "of the same caliber," so more research needs to be done, Dr. Schanler said.
"We’re talking about millions of children, so you really have to make sure there’s enough evidence to make a change," he said.
In their letter to Pediatrics (published online Oct. 28), the Section on Breastfeeding also faulted Dr. Greer and his colleagues for not discussing the possibility of delayed umbilical cord clamping as an alternative to iron supplementation. In theory, a significant amount of blood flows from the placenta to the newborn infant in the few minutes after birth. "There are data to suggest you increase red blood cell mass that way," said Dr. Schanler. "To me, if you’re writing guidelines you should at least comment that there’s another way to increase iron stores."
Dr. Greer responded that cord-clamping doesn’t concern pediatricians. "That’s a great idea," he said. "But we can’t really recommend it if obstetricians don’t do it."
In fact, the idea has not gained traction among obstetricians, said Dr. E. Albert Reece, the John Z. and Akiko K. Bowers Distinguished Professor and dean of the School of Medicine at the University of Maryland, Baltimore.
"I’m not aware of any movement afoot in the obstetrics community to prolong the time before cord clamping," said Dr. Reece, an ob.gyn. who specializes in maternal-fetal medicine. "The data now is very sparse to show that delayed cord clamping results in any substantial benefit. And even if it did enhance the iron store of the infant initially, the iron store would still decline."