Iron, Zinc, and Vitamin D Supplementation During Breastfeeding
Publication Date: February 28, 2019
Last Updated: March 14, 2022
Recommendations
Iron
Iron supplementation is not required for the non-anemic breastfeeding mother. Iron supplementation to the 4-monthold full-term, exclusively breastfed infant is associated with improved hematological indices. However, the long-term benefit of improved hematologic indices at 4–6 months is not known. If iron supplementation is given before 6 months, it should be given as a 1 mg/kg/day distinct iron supplement until iron-fortified cereals (7–7.5 mg ferrous sulfate/day) or other iron-rich foods such as meat, tofu, beans, and others are initiated at 6 months of age with other complementary foods. (IB)
326858
Zinc
Zinc supplementation, above dietary intake, to the lactating mother or breastfeeding infant is not associated with improved outcomes and, therefore, is not recommended. (IB)
326858
Vitamin D
The breastfeeding infant should receive vitamin D supplementation shortly after birth in doses of 10–20 lg/day (400–800 IU/day). (IB)
326858
This supplement should be cholecalciferol, vitamin D3, because of superior absorption unless a vegetable source such as ergocaliferol vitamin D2, is desired. (IIA)
326858
Randomized trials demonstrate that safe vitamin D supplementation may be provided to a nursing mother to achieve healthy vitamin D status in her breastfeeding infant, when there is objection or contraindication to direct infant supplementation. A maternal dose of 160 lg/day (6,400 IU/day) is suggested.
Iron
Iron-deficiency anemia is diagnosed by abnormal hematological values. Studies of iron supplementation in infants have used serum iron, ferritin, iron binding capacity, mean corpuscular volume (MCV), and hemoglobin as indicators of sufficient iron to avoid the risk of anemia. Other potential markers of adequate iron supplementation include anthropemetric growth and neurodevelopment. Randomized controlled trials of iron supplementation to the lactating mother or to the infant have included serum and milk iron concentrations, ferritin and iron binding capacity, hematologic indices, growth, and neurodevelopment as outcomes. (IB)
326858
There are few studies investigating iron supplementation directly to the breastfeeding mother to support infant iron status. One study recruited 168 healthy, nonanemic mothers in the first 10–20 postnatal days if they planned to exclusively breastfeed for at least 4 months. These mothers were randomized to receive 80 mg elemental iron daily or placebo. No difference was seen in maternal or infant iron studies, rate of iron-deficiency anemia, or infant growth. In the intervention group, both mother and infant had significantly increased serum iron binding capacity but the significance of this single difference is not known. (IB)
326858
When evaluating the evidence of direct infant supplementation, it is necessary to consider the age at which supplementation occurred—in the first 4 months, starting at 4–6 months, or starting at 6 months of age. Two small randomized controlled trials have evaluated iron supplementation initiated before 4 months of age. The first study included 77 term breastfed infants who were randomized to receive either 7.5 mg elemental iron as ferrous sulfate or placebo from 1 to 6 months of age. (IB)
At 6 months, the supplemented group had significantly higher hemoglobin (124 versus 116 g/L) and MCV (81 versus 77 fL). Forty-six of the 77 study subjects had neurodevelopmental assessment at 12–18 months; the intervention group exhibited higher Bayley psychomotor development indexes and visual acuity. No significant differences were seen in mental development indices.
326858
A second study of early iron supplementation specifically focused on the term low birth weight (<2,500 g) infant. Healthy infants (n = 62) who were predominantly breastfed at 50–80 days were randomized to iron 3 mg/kg/day (25 mg Fe/mL ferric ammonia citrate) or placebo for 8 weeks. (IB)
Infant hemoglobin levels were significantly higher in the iron-supplemented group at 2 months of therapy (117 versus 107 g/L). No difference was found between groups in serum ferritin, infant growth, or morbidity. These two studies of early iron supplementation suggest that early iron may lead to higher hemoglobin levels, but the studies are too small to promote a specific recommendation for the breastfed term infant. Given small sample size and significant methodologic limitations, we cannot draw conculsions about the effect of early iron supplementation for term newborns on neurodevelopmental outcomes.
326858
Large randomized controlled trials have examined iron supplementation at 4–9 months of age. Some studies have specifically compared iron initiation at 4 or 6 months. Others have compared iron drops and iron-fortified foods. In one study of 609 infants in Thailand, both iron and zinc supplementation were evaluated with initiation at 4–6 months. Infants receiving 10 mg iron as iron sulfate (with or without zinc) exhibited significantly higher hemoglobin and ferritin concentrations at 6 months of therapy compared with infants receiving only zinc or placebo. When controlling for gender and birth weight, infants receiving iron had significantly higher Ponderal weight growth and weight-for-length z-score. (IB)
326858
One double-blinded randomized placebo-controlled trial, occurring in Honduras and Sweden, evaluated iron supplementation alone. In this study, 232 near-exclusive or exclusively breastfeeding infants at 4 months of age were randomized to receive (1) placebo until 9 months of age, (2) placebo for 4–6 months followed by iron (1 mg/kg/day) for 6–9 months, or (3) iron (1 mg/kg/day) until at least 9 months. The primary aim, to detect a difference in hemoglobin, was demonstrated for the infants receiving iron supplementation starting at 4 months. When iron supplementation started at 6 months, the infants in Honduras demonstrated significantly higher hemoglobin while the Swedish infants did not. (IB)
326858
In evaluation of growth, the Swedish infants supplemented with iron had significantly lower length and head circumference gains than those infants receiving placebo from 4 to 9 months. (IB)
In Honduras, a negative effect on linear growth was evident at 4–6 months only among iron-sufficient infants (with an initial Hb ≥110 g/L). In addition, in both sites, iron supplementation increased the likelihood of diarrhea among iron-sufficient infants.
326858
The question as to whether iron should be provided as a daily or weekly dose has been evaluated by one randomized trial without study blinding. No difference in iron deficiency or iron-deficiency anemia was observed with ferrous sulfate suspension dosed at 1 mg/kg daily, 7 mg/kg weekly, versus no supplement provided to breastfeeding infants at 4–10 months of age (n = 79). (IB)
326858
Studies of whether iron should be provided as a distinct dose or instead through fortified cereal are open-label studies. In 2004 in Honduras, 4-month-old, exclusively breastfeeding infants were randomized to iron-fortified cereal or no cereal until 6 months of age. (IB)
326858
Further study of iron-fortified cereal has occurred in the United States. The first study was an open-label randomized trial comparing iron drops (7-7.5 mg ferrous sulfate/day), iron-fortified cereal (7-7.5 mg ferrous sulfate/day), and no intervention from 4 to 9 months of age in 93 infants who were exclusively breastfeeding at 1 month. (IB)
326858
Further study of iron-fortified cereal compared electrolytic iron (54.5 mg Fe/100 g cereal) and ferrous fumarate (52.2 mg Fe/100 g cereal) from 4 to 9 months and demonstrated no difference in iron deficiency or iron-deficiency anemia between groups (n = 95). (IB)
326858
Iron supplementation is not required for the nonanemic breastfeeding mother. Iron supplementation to the 4-monthold full-term, exclusively breastfed infant is associated with improved hematological indices. However, the long-term benefit of improved hematologic indices at 4-6 months is not known. There are potential harms of iron supplementation, especially on immune function and in possibly decreasing the bioavailability of iron contained in human milk. In addition, there is potential harm in infant growth and morbidity when iron supplementation is provided to iron-sufficient infants. If iron supplementation is given before 6 months, it should be given as a 1 mg/kg/day distinct iron supplement until ironfortified cereals (7-7.5 mg ferrous sulfate/day) or other ironrich foods such as meat, tofu, beans, and the like are initiated at 6 months of age with other complementary foods. (IB)
326858
Recommendation Grading
Overview
Title
Iron, Zinc, and Vitamin D Supplementation During Breastfeeding
Authoring Organization
Academy of Breastfeeding Medicine
Publication Month/Year
February 28, 2019
Last Updated Month/Year
June 9, 2022
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Target Patient Population
Breastfeeding mothers
Inclusion Criteria
Female, Adult, Infant
Health Care Settings
Ambulatory, Emergency care, Hospital, Outpatient
Intended Users
Nurse midwife, nurse, nurse practitioner, physician, physician assistant
Scope
Counseling, Management
Diseases/Conditions (MeSH)
D000755 - Anemia, Sickle Cell, D000740 - Anemia, D001942 - Breast Feeding, D015032 - Zinc, D007501 - Iron, D018798 - Anemia, Iron-Deficiency, D014808 - Vitamin D Deficiency
Keywords
lactation, Breastfeeding, Lactation, vitamins and breastfeeding, vitamin supplementation during breastfeeding, premature nutrition
Methodology
Number of Source Documents
46
Literature Search Start Date
January 1, 1977
Literature Search End Date
December 31, 2018
Specialties Involved
Critical Care, Emergency Medicine, Endocrinology, Family Medicine, Hematology, Internal Medicine General, Obstetrics And Gynecology, Pediatrics, Neonatology And Perinatology, Pediatrics
Description of Evidence Grading
Quality of evidence (levels of evidence [LOE] IA, IB, IIA, IIB, III, and IV) is provided and based on levels of evidence used for the National Guidelines Clearing House