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Iron Supplements for Breastfed Babies: OK or Dangerous?

I was recently surprised to see that the American Academy of Pediatrics has issued a new recommendation on iron supplementation for breastfed babies. The AAP now recommends that an iron supplement be started at 4 months for exclusively breastfed babies, and continued until iron fortified solids are introduced.

I read this with interest both because I have a baby who is about this age and also because a few years ago I wrote about how my pediatrician stopped recommending such supplementation (for babies who are now low in iron) after I provided a study on iron supplements and breastfed babies which found that this causes slower growth, smaller head circumference, and more diarrhea.*

Back then I explained:

Why is giving iron supplements to exclusively breastfed babies - who are not iron deficient - a problem? The theory has to do with the function of lactoferrin, an important component of breastmilk. Lactoferrin has the job of binding with iron in the baby's gut and getting it absorbed into the baby's system. In doing so this component of breastmilk deprives bad bacteria (E.coli, Staphylococcus, etc.) of their favorite food source: iron. If extra iron is given to the baby, the lactoferrin in breastmilk gets "overwhelmed" and can't bind with all of the iron. This leaves extra iron in the system to fuel those bad bacteria. There is even some suggestion that extra iron reduces the ability of lactoferrin to bind with the iron in breastmilk, resulting in the baby getting less of the available iron. In this case, less is more.

So what prompted the new recommendation? It was a study from 2003. Susan Burger, an IBCLC with a doctorate in nutrition wrote an excellent analysis on this study on Nancy Mohrbacher's blog.  She writes that the sample size was small (77), the dropout rate high, and compliance with the supplementation guidelines low. In addition, the babies enrolled in the study weren't the same population as the one the AAP is recommending iron for - they started supplements at 1 month of age instead of 4, and the babies in the study weren't even exclusively breastfed. She also notes that the authors of the study even cautioned against the use of its results to form recommendations.

But most interestingly, she links to a letter written to Pediatrics (in which the recommendation was published) from the AAP Section on Breastfeeding (yes, the same organization as the one making the recommendation), objecting to the new recommendation.

Among the concerns the AAP Section on Breastfeeding raised were: 1) the sample size and limitations of the study cited above, 2) no mention of the possible adverse outcomes of supplementation or differences in bioavailability were included in the recommendation, 3) no mention was made of the fact that the prevalance of iron deficiency anemia among exlusively breastfed infants in the first 6 months is low (3%) and finally 4) that there was no mention of the fact that the AAP Section on Breastfeeding actually objected to this recommendation when presented with it 2 years ago. This last issue, the letter states, "is wrong and will mislead the medical community."

The letter states, "Given that research has shown potential harm in infant growth and morbidity when iron supplementation is provided to iron-sufficient infants one wonders if universal iron supplementation will be deleterious to the population of developing infants who are breastfeeding exclusively."

What does the AAP Section on Breastfeeding suggest as an alternative to this policy? Delayed cord clamping at birth and screening for at-risk babies at 6 months. 

When I saw the new recommendation I had a moment of panic that I'd done something wrong by not giving my son and daughter iron supplements.  But after reading all this (and knowing the circumstances of their births) I feel a lot more comfortable.

* Iron deficiency is a serious problem, and iron supplementation is critical if a baby is iron deficient.  For more on the topic, see this page on, and of course consult with your pediatrician for medical advice suited to your own situation.

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