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Evidence-based strategy to minimise iron deficiency in infants
Exclusively breastfeed to 6 months Susan Tawia
BSc PhD Dip Ed Dip Breastfeeding Management
ABA Community Educator
Manager
Breastfeeding Information and Research
Australian Breastfeeding Association
2013 NHMRC Australian Infant Feeding Guidelines
‘The Infant Feeding Guidelines are aimed at health workers to assist them in providing consistent advice to the general public about breastfeeding and infant feeding.’
‘They support optimum infant nutrition by providing a review of the evidence, and clear evidence-based recommendations on infant feeding for health workers.’
2013 NHMRC Australian Infant Feeding
Guidelines
Recommendations:
• Encourage, support and promote exclusive breastfeeding to around 6 months of age.
• Continue breastfeeding while introducing appropriate solid foods until 12 months of age and beyond, for as long as the mother and child desire.
• While breastfeeding is recommended for the first 6 to 12 months and beyond, any breastfeeding is beneficial to the infant and mother.
Accessible versions of Australian Dietary Guidelines resources
www.eatforhealth.gov.au
• Brochures
• Posters
• Infant Feeding Guidelines: information for health workers (2012)
• Infant Feeding Guidelines: summary
https://www.eatforhealth.gov.au/accessible-versions-australian-dietary-guidelines-resources
Accessible versions of Australian Dietary Guidelines resources
The Australian Dietary Guidelines
• from 2 years of age onwards
• pregnant and breastfeeding women
https://www.eatforhealth.gov.au/guidelines
Translated versions of the Australian Dietary Guidelines (but not Infant Feeding Guidelines)
http://www.mhcs.health.nsw.gov.au/publicationsandresources/pdf/publication-pdfs/oth-9450
Why focus on iron?
Iron deficiency anaemia is the most
common micronutrient deficiency
worldwide
Infants and young children are at
particular risk since their rapid growth
leads to high iron requirements
Iron is crucial for brain development
Excessive iron intakes may be
detrimental to infant growth
Exclusive breastfeeding
Breastmilk (including expressed milk or from a wet nurse), oral rehydration salts, syrups (vitamins, minerals, medicines) and nothing else, not even water.
Infants should be exclusively breastfed for the first six months of life to achieve optimal growth, development and health
WHO and UNICEF Global Strategy for Infant and Young Child Feeding 2003
Infants who are not exclusively breastfed have significantly:
• More gastrointestinal, respiratory tract infections and ear infections (otitis media) in the first year
• More visits to the doctor
• More antibiotics
• More hospitalisations for gastrointestinal and respiratory tract infections (5-fold increase)
• More ear, nose and throat infections at 6 years of age
• Increased risk of developing overweight/obesity later in life
For review see Tawia March 2011 Topics in Breastfeeding SET XXIII ABA
Li R, Dee D, Li CM, Hoffman HJ, Grummer-Strawn LM 2014 Pediatrics, 134(Suppl 1), S13-S20
Duration of exclusive breastfeeding and risk of infectious disease in the first 6 months of life
Duration of breastfeeding
URTI LRTI GI % (n)
Odds Ratio (95% CI)
Odds Ratio (95% CI)
Odds Ratio (95% CI)
Generation R study, Netherlands 2002-2006
Never breastfed 1.00 1.00 1.00 12.5 (519)
Partially for < 4 mo, not breastfed after
0.96 (0.76-1.21 1.01 (0.68-1.50) 0.77 (0.52-1.15) 29.2 (1182)
Partially for 4-6 mo 0.85 (0.67-1.07)
0.89 (0.60-1.34) 0.72 (0.48-1.09) 28.8 (1166)
Exclusively for 4 mo, not breasted after
0.70 (0.41-1.20) 0.39 (0.12-1.31) 1.01 (0.44-2.38) 2.0 (80)
Exclusively for 4 mo, partially breastfed after
0.65 (0.51-0.83) p<0.01
0.50 (0.32-0.79) p<0.01
0.41 (0.32-0.79) p<0.01
25.7 (1037)
Exclusively breastfed for 6 mo
0.37 (0.18-0.74) p<0.01
0.33 (0.08-1.40) 0.46 (0.14-1.59) 1.4 (58)
Duijts et al 2010 Pediatrics
Duration of exclusive breastfeeding and risk of infectious disease in the first 6 months of life
Duration of breastfeeding
GI % (n)
Odds Ratio (95% CI)
Generation R study, Netherlands 2002-2006
Never breastfed 1.00 12.5 (519)
Partially for < 4 mo, not breastfed after
0.77 (0.52-1.15) 29.2 (1182)
Partially for 4-6 mo 0.72 (0.48-1.09) 28.8 (1166)
Exclusively for 4 mo, not breasted after
1.01 (0.44-2.38) 2.0 (80)
Exclusively for 4 mo, partially breastfed after
0.41 (0.32-0.79) p<0.01
25.7 (1037)
Exclusively breastfed for 6 mo
0.46 (0.14-1.59) 1.4 (58)
Duijts et al 2010 Pediatrics
Duration of exclusive breastfeeding and risk of infectious disease in the first 6 months of life
0
0.2
0.4
0.6
0.8
1
1.2
URTI LRTI GI
Od
ds
Rat
io
Never breastfed
Partially for <for 4 mo
Partially for 4-6 mo
Exclusively for 4 mo
Exclusively for 4 mo, partially after
Exlusively for 6 mo
Past-year infections among 6-year-old US children, exclusively breastfed as infants
Infant Feeding Practices Study II
0
10
20
30
40
50
60
70
80
Cold or URT p=0.44 Ear p<0.01* Throat p<0.01* Sinus p<0.01* Pneumonia or lung p=0.41
Urinary tract p=0.63
Pe
rcen
tage
Duration of exclusive breastfeeding
>0 to <4 months 4 to < 6months ≥ 6 months
Li R, Dee D, Li CM, Hoffman HJ, Grummer-Strawn LM 2014 Pediatrics, 134 (Suppl 1) S13-S20
Factors that have a negative effect on infant iron status in the perinatal period
• Maternal iron deficiency or anaemia
• Maternal smoking
• Poorly-controlled gestational diabetes
• Multiple gestation
• Intrauterine growth restriction
• Preterm birth
• Foetal haemorrhage
• Uncompensated phlebotomy losses
• Early umbilical cord clamping
• Cord blood collection – 50 to 150ml
Healthy, full-term, normal birth weight, exclusively-breastfed infants born to well, non-smoking mothers who were iron sufficient during pregnancy........
Infant haemoglobin
at birth, total body iron - 75% haemoglobin + 25% iron stores
at birth, average infant haemoglobin is high – 170 g/L
during the first 6 weeks haemoglobin levels drop to about 120 g/L
Domellof et al 2011 Ann Nutr Metab 59: 59-63
Infant ferritin
at birth, the median serum ferritin level, which reflects iron storage levels in the body, is 101 μg/L
at 1 month, serum ferritin rises to 356 μg/L, indicating an increase in iron stores, which occurs as haemoglobin is released from red blood cells
at 6 months serum ferritin drops to 30 μg/L
Siimes et al 1974, Blood 43: 581-590
Due to redistribution of iron from haemoglobin to iron stores, healthy, full-term, normal birth weight infants are virtually self sufficient with regard to iron during the first 6 months of life and around that age, iron becomes a critical nutrient
Recommended daily dietary iron intakes (RDI) for young children
RDI
Iron
Group mg/day
________________________________
Infants
0–6 months 0.2*
7–12 months 11
Children
1–3 years 9
4–8 years 10
________________________________
*Adequate intake for 0-6 months calculated by multiplying the average intake of breastmilk (0.78 L/day) by the average concentration of iron in breastmilk (0.26 mg/L)
Source: Department of Health and Ageing, National Health and Medical Research Council 2006, Nutrient Reference Values for Australia and New Zealand. Commonwealth of Australia.
Iron content of breastmilk and foods
Food Iron content
Breastmilk – day 1 0.089 mg/100mL*
Breastmilk – 6 months 0.026 mg/100mL*
Beef 4.4 mg/100g
Tofu 5.2 mg/100g
Chicken 0.9 mg/100g
Spinach 2.0 mg/100g
Brown rice 0.5 mg/100g
Fresh fruit 0.2-0.7 mg/100g
*Raj et al 2008 International Breastfeeding Journal 3:3
Breastmilk micronutrients
Although the absolute amounts of vitamins, minerals and trace elements may appear to be low in breastmilk, their bioavailability is usually high and a range of mechanisms exist which enhance their absorption
Breastmilk iron bioavailability
As much as 70% of the iron in breastmilk is absorbed by the infant compared to 30% from cows’ milk and 10% from artificial baby milk
Saarinen & Siimes 1979, Pediatr Res 13: 143-147
The high bioavailability of iron in breastmilk comes about because of several factors, including the binding of iron to the iron-binding protein, lactoferrin
Assessment of anaemia and iron-deficiency anaemia in Australian preschool children and
infants
Australian Iron Deficiency Expert Group 2010 MJA 93: 525-532
Reasons for iron-deficiency anaemia in infants and young children
• Inadequate dietary iron
• Inadequate complementary foods (excess cow’s milk ingestion)
• Cows’ milk allergy
• Rapid/rebound growth, low birth weight
• Coeliac disease
• Parasitic infection
• Gastrointestinal blood loss
Australian Iron Deficiency Expert Group 2010 MJA 93: 525-532
Iron sufficiency of exclusively-breastfed infants
A prospective study of iron status in exclusively breastfed term infants up to 6 months of age
Can exclusive breastfeeding until six months of age maintain optimum iron status in term babies?
• prospective cohort study in Delhi, India
• normally delivered babies of non-anaemic and anaemic mothers
Exclusively breastfed infants of non-anaemic and anaemic mothers did not develop iron deficiency or iron deficiency anemia by six months of age. Raj et al 2008 International Breastfeeding Journal 3:3
Breastmilk component
Non-anaemic mothers
Anaemic mothers
Iron - day 1 0.89 mg/L 0.86 mg/L
Iron – 6 months 0.26 mg/L 0.27 mg/L
Iron regulation in the breastfed infant
Infants are able to increase iron absorption from breastmilk in response to low iron stores
Iron deficiency upregulates iron absorption in breastfed infants at both 5-6 and 9-10 months
Infants with serum ferritin <12 µg/L had significantly higher iron absorption than those with >12 µg/L
Hicks et al 2006 J Nutr 136: 2435-2438
Homeostasis
Iron deficiency is part of a normal homeostatic mechanism which increases iron uptake when infants are iron deficient
Some iron deficiency is to be expected in a population of exclusively-breastfed infants
Iron uptake
Iron levels
Iron supplementation of exclusively breastfed infants
Infants under 6 months cannot downregulate their iron intake so iron supplementation may, in fact, be detrimental
Iron supplementation may adversely affect the growth of iron-sufficient infants and children
Domellöff et al 2002 Am J Clin Nutr 76: 198-204
Iron supplementation of exclusively breastfed infants
Sweden – low dose iron 4-9 mo had a negative effect on linear growth and head circumference
Honduras – low dose iron 4-6 mo had a negative effect on linear growth in infants with Hb ≥ 110 g/L
Routine iron supplementation of breast-fed infants may benefit those with low Hb but may present risks for those with normal Hb
Dewey et al 2002 J Nutr 132: 3249-3255
How do well infants develop iron deficiency or iron-deficiency anaemia?
gastrointestinal bleeding
inhibition of iron uptake from breastmilk by complementary foods
displacement of breastmilk by low-iron content complementary foods
………..but, first a word about cows’ milk
Cows’ milk and iron deficiency
The introduction of whole cows' milk before 12 months is a confirmed risk factor for iron deficiency
An Australian study found that the proportion of iron-deficient infants (ferritin ≤ 10 µg/mL) given whole cows' milk before 12 months was almost double that of iron-sufficient children
Mira et al 1996 BMJ 312: 881-883
How do infants develop iron deficiency or iron-deficiency anaemia?
1. Gastrointestinal bleeding
Gastrointestinal bleeding in infants
Infant feeding guidelines related to cows’ milk
Research lead to the universally-adopted
recommendation, including the current NHMRC 2013
Australian Infant Feeding Guidelines, that:
• infants shouldn’t receive cows’ milk as their main
milk drink before 12 months and
• before 12 months cows’ milk should only be used
in small amounts
What are Australian infants drinking and
eating at 4 and 6 months?
83.2
28.7
0 0.7 0.7
18.5
2.2 6.6 7.3
0.7
21.2
77.6
46.3
1.5
20.4
4.5
79.6
48.8
83.6 85.4
24.9
98.4
0
10
20
30
40
50
60
70
80
90
100
Per
cen
tage
4524
The Feeding Queensland Babies Study (Newby & Davies 2014)
How do infants develop iron deficiency or iron-deficiency anaemia?
2. Inhibition of iron uptake from breastmilk by complementary foods
Dietary compounds that inhibit the absorption of non-haem iron
Phytates
• Cereals, grains, seeds, nuts, vegetables and fruit
• Bind iron making it unavailable for absorption
Fibre
• Cereals
• Inhibits iron absorption
Cereals are a common first food for infants and may be inhibiting the absorption of iron from breastmilk
Michaelson et al 2009 Food Nutr Bull 30:S343-S404.
Inhibition of iron uptake from breastmilk by complementary foods
Adult men drank 100ml of breastmilk containing radioactively-labelled iron with and without 128g of strained pears
Pears reduced iron absorption by 76%
The bioavailability of breastmilk iron was dramatically reduced by pears - a common first food for infants
No similar studies have been done in infants
Oski & Landaw 1980 Am J Dis Child 134: 459-465
Inhibition of iron uptake from breastmilk by complementary foods
Adult men drank breastmilk and cows’ milk containing radioactively-labelled iron
Iron absorption from breastmilk was 37.3%
Iron absorption from cows’ milk was 15.5%
Adding calcium to breastmilk reduced iron absorption to 19.2%
Calcium in breastmilk 200-340 mg/L, cows’ milk 1250 mg/L
No similar studies have been conducted in infants
Hallberg et al 1992 Pediatr Res 31: 524-527
How do infants develop iron deficiency or iron-deficiency anaemia?
3. Displacement of breastmilk by low iron content complementary foods
Displacement of breastmilk by low iron content complementary foods
2013 NHMRC Australian Infant Feeding Guidelines state:
it is recommended that infants be exclusively breastfed until around 6 months when solid foods are introduced
introduce solids at around 6 months
to prevent iron deficiency, iron-containing nutritious foods are recommended to be included
Proportion of children receiving food at each month of age from 0 to 8 months
Source: 2010 Australian National Infant Feeding Survey 2011
0 0.7 2.2
9.7
35.3
70.2
91.5 94.3 94.7
0
10
20
30
40
50
60
70
80
90
100
<1 1 2 3 4 5 6 7 8
Pe
rce
nta
ge
Age in completed months
What are Australian infants eating and drinking at 4 and 6 months?
83.2
28.7
0 0.7 0.7
18.5
2.2 6.6 7.3
0.7
21.2
77.6
46.3
1.5
20.4
4.5
79.6
48.8
83.6 85.4
24.9
98.4
0
10
20
30
40
50
60
70
80
90
100
Per
cen
tage
The Feeding Queensland Babies Study (Newby & Davies 2014)
What’s wrong with introducing solids before around 6 months?
Just a reminder…that introducing solids early means infants are not being exclusively breastfed to 6 months and that leads to …
• More gastrointestinal, respiratory tract infections and ear infections (otitis media) in the first year
• More visits to the doctor
• More antibiotics
• More hospitalisations for gastrointestinal and respiratory tract infections (5-fold increase)
• More ear, nose and throat infections at 6 years of age
• Increased risk of developing overweight/obesity later in life
Exclusive breastfeeding rates in Australia 2010 Australian National Infant Feeding Survey
90.4
61.4 55.8
48
39.2
27
15.4
0
10
20
30
40
50
60
70
80
90
100
Initiation < 1 < 2 < 3 < 4 < 5 < 6
Pe
rce
nta
ge
Months of exclusive breastfeeding
Percentage of NSW infants breastfed to 6 months 2004-2014
Health Stats NSW
12.8 16.3 17.7
20.5 25 22.9
0
10
20
30
40
50
60
70
80
90
100
2004 2006 2008 2010 2012 2014
http://www.healthstats.nsw.gov.au/indicator/beh_breastfeed_age
Exclusive breastfeeding rates of ABA trainee counsellors and community educators
ABA EMBER study
6.3
1.6
7.9 7.9
49.2
7.9 4.8
1.6 1.6 1.6
0
10
20
30
40
50
60
4 4.5 5 5.5 6 6.5 7 8 9 10
Pe
rce
nta
ge
Months
ABA trainee counsellors and community educators
EMBER study
These women had:
• a strong intention to breastfeed
• high levels of breastfeeding knowledge
• confidence in their ability to breastfeed
• strong partner support and
• appropriate and effective peer support
• breastfeeding was ‘normalised’ in their lives
• the same kinds of problems, if not worse compared with the general population (reason for seeking help from ABA and/or LCs)
Prevalence of iron deficiency or iron-deficiency anaemia in Australian infants and young children
aged 6 to 24 months
69
25
6
72
14 14
0
10
20
30
40
50
60
70
80
90
100
iron sufficient iron deficient anaemic due to iron deficiency
Caucasian
Asian
Oti-Boateng et al 1998, J Paediatr Child Health 34: 250-253
Foods, nutrients and portions consumed by Australian children aged 16–24 months
Diets were characterised by large amounts of milk and non-milk drinks with smaller amounts of cereals, fruits, vegetables and meats
One third of childrens’ energy came from milk
milk and milk products
cereals
cereal-based products
non-milk drinks
food Webb et al 2008 Nutrition & Dietetics 65: 56–65
To prevent iron deficiency in infants
1. exclusively breastfeed to 6 months
2. don’t damage the gut with inappropriate introduction of foods or drinks
3. don’t inhibit the absorption of iron and
4. don’t displace breastmilk with iron-poor substitutes
5. introduce good-quality complementary foods, including those that are iron-rich
Conclusion
Healthy, full-term, normal birth weight,
exclusively-breastfed infant born to a well, non-
smoking mother who was iron sufficient during
pregnancy….
Conclusion
1. will have sufficient iron for at least 6 months,
when appropriate iron-rich complementary
foods can be introduced
2. does not need to be supplemented with iron
and because infants under 6 months cannot
regulate their iron intake, iron
supplementation may, in fact, be detrimental
Allergy and infant feeding guidelines
‘ASCIA Infant Feeding Advice is intended to provide families in Australia and New Zealand with a summary of evidence based information on infant feeding, including an explanation as to why families may choose to introduce solid foods to their infants from 4-6 months (whilst breastfeeding) and not delay the introduction of potentially allergenic foods, to prevent allergy.’ Australian Society of Clinical Immunology and Allergy website
The NHMRC Infant Feeding Guidelines were developed to assist health professionals to promote and support exclusive breastfeeding to around 6 months and then the introduction of good-quality complementary foods.
Despite this clear and unambiguous recommendation, there is confusion around infant feeding advice. This is creating a situation where families believe that the introduction of solids before 6 months is necessary to reduce allergies when, in fact, the evidence shows that stopping exclusive breastfeeding before 6 months puts them at increased risk of infections and the consequences of infections and overweight and obesity.
Allergy and infant feeding guidelines
Who is responsible for this confusion? Professor Katie Allen, a member of the steering committee of the National Allergy Strategy, stated in a 2013 review paper that:
‘The recent change in position by specialty allergy bodies around the world has now lead to a contradistinction between government, WHO and peak expert body infant feeding guidelines which is likely to further confuse the public about which guidelines and undermine their credibility.’ (Koplin & Allen, 2013).
Contradicting the WHO and NHMRC, ASCIA and other peak allergy bodies around the world recommend introducing complementary solid foods from 4 to 6 months.
Koplin, J. J., & Allen, K. J. (2013). Optimal timing for solids introduction–why are the guidelines always changing?. Clinical & Experimental Allergy, 43(8), 826-834.
Allergy and infant feeding guidelines
Australian infants are being introduced to solids well before 6 months, with 9.7% of Australian infants were being introduced to solids at 3 months, 35.3% at 4 months and 70.2% at 5 months
The question of whether the rise in allergies, particularly food allergies, can be explained solely by the timing of the introduction of solids at 6 months has not been resolved. Again, Professor Katie Allen states:
‘Changes in the timing of food introduction may contribute to but unlikely to completely explain recent increases in the prevalence of food allergy. Existing studies show that some children will develop food allergy despite early introduction of potentially allergenic foods while others do not develop food allergy despite the delayed introduction of these foods, providing evidence that other environmental or genetic factors play a role in the development of food allergy.’ (Koplin & Allen, 2013)
Allergy and infant feeding guidelines
So, confusion has been created around infant feeding guidelines with little evidence that the introduction of solids before 6 months reduces the incidence of food allergies. Coupled with the growing body of evidence that the introduction of solids before 6 months can cause harm, this situation is putting the health of infants and children at risk.
‘There is as yet insufficient evidence to inform the question as to whether changing in feeding practices may contribute to the rise in food allergy. More evidence about the role of infant diet in the development of food allergy will be become available in the next few years with the impending completion of several randomized controlled trials around the world.’ (Koplin & Allen, 2013)
Guideline: delayed cord clamping WHO 2014
From 2012 WHO guidelines on basic newborn resuscitation:
• In newly born term or preterm babies who do not require positive-pressure ventilation, the cord should not be clamped earlier than 1 min after birth (strong recommendation).
• When newly born term or preterm babies require positive-pressure ventilation, the cord should be clamped and cut to allow effective ventilation to be performed (conditional recommendation).
• Newly born babies who do not breathe spontaneously after thorough drying should be stimulated by rubbing the back 2–3 times before clamping the cord and initiating positive-pressure ventilation(conditional recommendation).
Guideline: delayed cord clamping WHO 2014
From 2012 WHO recommendations for the prevention and treatment of postpartum haemorrhage:
• Late cord clamping (performed approximately 1–3 min after birth) is recommended for all births, whileinitiating simultaneous essential neonatal care (strong recommendation).
• Early umbilical cord clamping (less than 1 min after birth) is not recommended unless the neonate is asphyxiated and needs to be moved immediately for resuscitation (strong recommendation).
In summary:
• Delayed umbilical cord clamping (not earlier than 1 min after birth) is recommended for improved maternal and infant health and nutrition outcomes.
