Iron Deficiency and the Breastfed Baby

“He’s iron-deficient.”

“She’s slightly anemic.”

I hear it often: mothers take their babies to the clinic for a well baby check up, have blood drawn and summarily learn that their baby is deficient in iron and needs supplementation. Or, if your baby’s doctor is like ours was you simply receive a prescription for iron supplementation at 9 months, because “All breastfed babies are iron deficient.”

Are So Many Babies Truly Iron-deficient?

It seems to me that a baby fed from the breasts of a well-nourished mother as nature intended is unlikely to be deficient in such a critical mineral. After all, breastfeeding was the cross-cultural norm for millennia until the middle of the 20th century. How could evolution and nature favor deficiency? Perhaps, instead, our perception of optimal iron levels in infants is skewed.

You see, babies receive their iron stores from their mothers’ bodies, and pregnancy favors the growing infant over the mother. That is: pregnancy is a condition in which a mothers body is more likely to deplete her own iron stores than to withhold iron from the growing fetus. As such, unless a mother is under-nourished and already suffering from depleted iron stores prior to conception, it is likely that her baby will be born with sufficient, optimal iron stores. Following birth, infants that are breastfed receive iron not only receive iron through their mothers’ milk, but also reap the benefits of lactoferrin and transferrin. Moreover, iron in human breast milk is very easily absorbed. Indeed, infants will absorb an average of 49% of iron in breastmilk. Compare that to the 10% they absorb from cow’s milk formula1.

An optimal iron status in the mother coupled with delayed cord clamping and exclusive breastfeeding offers sufficient iron stores in the breastfed baby for at least six to eight months or longer2. Similarly, babies breastfed exclusively for seven months had higher hemoglobin levels at 1 and 2 years compared to babies introduced to solid foods prior to seven months3. Breastfed babies from healthy, non-deficient mothers receive plenty of iron through natural mechanisms.

Iron Supplementation: A Poor Choice for Breastfed Babies

Iron supplementation is a poor choice for breastfed infants, particularly if supplementation is applied across the board, to every baby as my (former) doctor recommended we do. Indeed, iron supplementation may even prove dangerous. Supplemental iron can take a long time to be effective, cause constipation and may be toxic if overused4. Lactoferrin and transferrin, found in human breast milk as well as other raw milks, binds iron and withholds it from pathogenic bacteria in the infant’s intestinal tract3.

When breastfed infants are supplemented with iron or given iron-fortified foods, the iron they ingest exceeds the ability of these specialized proteins to bind it, and, instead the supplemental iron may feed pathogenic bacteria and actually contribute to lower immunity3. Moreover, while iron supplementation may be effective for infants that are truly deficient, babies who are breastfed by non-anemic mothers may actually experience other adverse effects on their growth and overall health. For these babies, iron-rich foods, not supplementation, will be ideal in maintaining iron stores and staving off deficiency5.

Choose Naturally Iron-rich Foods

Instead of choosing supplements, boost your baby’s iron with real food. Iron, particularly heme-iron found in animal foods, can help to maintain iron stores endowed to the infant by the mother’s body during her pregnancy. While naturally iron-rich foods should play an important role in everyone’s diet, they can play an even more important role if you or your doctor suspects a true deficiency.

Iron-rich Foods6

Food

mg Iron / 100 grams

Braised Pork Liver 18 mg
Pan-fried Chicken Liver 13 mg
Liverwurst 9 mg
Steamed Clams 28 mg
Fish Roe 12 mg
Steamed Oysters 9 mg
Anchovies 5 mg
Marrow 4.5 mg
Molasses 16 g

Get the Most Out of Iron-rich Foods

Acidic foods and foods rich in vitamin C help the body to better absorb iron better. Similarly, fermented foods due to their acidic nature may increase iron absorption, so maximize the iron in your baby’s foods by serving them with something mildly acidic. Take care, though, as acidic foods may cause diaper rash or other reactions depending on the age of your baby. Take care to reduce the phytate content of the foods you serve as phytates can bind up iron and other minerals preventing their full absorption. If you serve grains to your baby or toddler, make sure they’re sprouted or soaked beforehand (learn more about sprouted grain.)

Take Action to Prevent Iron-deficiency in Your Baby

Since babies receive their iron stores from their mothers, mothers who are planning or trying to conceive should take great care of their bodies in anticipation of the challenges pregnancy presents. Eat iron-rich foods and take measures to reduce phytates and other antinutrients found in grain before and during pregnancy so that your body is not depleted. At birth, ask your midwife or attending physician to delay clamping and cutting your baby’s umbilical cord until after it stops pulsating. Breastfeed your baby without supplementation for at least 6 months, preferably longer before introducing wholesome foods. Skip the iron-fortified cereals in favor of naturally iron-rich foods.

Lastly, if you’ve done what you can and your baby is still iron-deficient, iron supplementation can fill a real and important purpose provided it’s not overused.

Sources:

  1. Iron absorption in infants: high bioavailability of breast milk iron as indicated by the extrinsic tag method of iron absorption and by the concentration of serum ferritin. The Journal of Pediatrics. 1977 Jul;91(1):36-9.
  2. Setting the stage for child health and development: prevention of iron deficiency in early infancy. The Journal of Nutrition. 2008 Dec;138(12):2529-33.
  3. The Womanly Art of Breastfeeding. 6th Revised Edition. La Leche League International. 1997. 340 – 341.
  4. Nature’s Pharmacy: Break the Drug Cycle with Safe Natural Treatments for 200 Everyday Ailments. Walker, et al. Reward Books. 1998. 52.
  5. Mineral metabolism and body composition iron status of breast-fed infants. The Proceedings of the Nutrition Society. 2007 Aug;66(3):412-22.
  6. NutritionData.com

Photo Credit: Anderson eating baby food, originally uploaded by mightyb.

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What people are saying

  1. says

    Great article. Rather than getting my babies blood drawn, we just look for external signs of anemia (lethargy, fatigue, paleness) and that’s good enough for my doctor and I. We also delay cord clamp, and don’t introduce solids til around 12 months.

  2. says

    I was a La Leche League Leader and lactation consultant, and when I was dealing with a mother whose baby was iron deficient one of my colleagues recommended besides the foods you mentioned above, cooking in cast iron. Frying apples and making applesauce that way, steaming veggies in a cast iron dust oven, etc. will allow even more iron to be absorbed into the food.

    Also, don’t give calcium foods with iron foods, since calcium blocks absorption.

    But you are right. The iron that is in breastmilk is much more readily absorbable than the iron in supplements. It may seem low to your doctor, looking at numbers, but the baby’s body uses nearly ALL of it, whereas only a small amount from iron supplements get absorbed, and can block the absorption of the iron in breastmilk.

  3. says

    Really good point–are they really deficient? I had several friends with “iron deficient” babies. That was years ago, I wish I would have thought about it more, because you are so right.

    For some reason (maybe because they your rediculously chubby babies and full of life) my kids were never once tested.

    On another note, my oldest son had to have his cholesterol tested at 6! California State Law requires that all kids by the time they start first grade get a comprehensive physical. Sad state of affairs when we are testing 6 year olds for cholesterol levels.

  4. says

    This is a pet peeve of mine – pregnant and breastfeeding women are told not to eat many of the foods in your list, rather than told to find safe sources of grass fed versions yet the first thing they are told to do is take a supplement made from isolated nutrients that their body not only doesn’t absorb but reacts negatively to (because it’s not food.)

    Of course we are iron deficient, we are malnourished. Is it any wonder infant mortality rates are up for the first time since records have been kept?

    Thanks so much for another great article!

  5. says

    My youngest who is 16 months was just diagnosed as iron deficient today and prescribed supplements. Thank you for this article. I’m torn about what to do. She doesn’t like a lot of meats and loves grains. Doesn’t like dairy. I’m questioning how good my milk is as well. I’ve had thyroid issues and dropped 100 pounds since she was born. I think I’m going to have to put more effort into our diets. Anyway, thanks for sharing this.

  6. karen c. says

    Hi Jenny, would you do a followup blog to this one on how to increase iron levels in toddlers and preschoolers, increase absorption, tricks on them eating those above? We eat NT but my girls (age 21 months and 4 yo) are still both suspect anemic.

  7. Dana says

    My little girl’s pediatrician-at-the-time (it’s a clinic with resident rotation rather than a consistent attending physician) told me, WITHOUT checking hemoglobin, that because Thea was breastfed she should get iron supplements. The doc handed me a prescription for infant vitamin/mineral drops. I never filled it.

    I mean, logically. Looking at this logically. How in the WORLD did we ever survive as a species if our babies weren’t getting enough iron???

    Shocker of shockers, Thea was not anemic at a year old. I did give her iron-fortified cereal, I didn’t know any better back then, but she was also BFed for something like eight months before she ever touched solids, and was a healthy, happy, and energetic baby with the exception of a kidney-related health problem having nothing to do with iron whatsoever.

    But they don’t check. They just don’t bother to check. They just *assume.*

  8. says

    Thanks for this post Jenny!

    I was given the prescription for both kids and with my first i gave it to her a couple of times (she hated it, naturally, the stuff is nasty!) i figured nature (Allah) knew better than us and i couldn’t understand how breastmilk could be anything but perfect! So i was never good with giving it to her and the Drs gave me grief about it and i just told them i would give it to her and didn’t. With number 2 i didn’t even fill the prescription. I’m actually quite anti supplementing breastfed babies with stuff like this, i don’t only think it’s unnecessary without an obvious deficiency, i think it’s wrong.

  9. says

    Great read. Iron has its place, and it’s true that iron deficiency can cause a whole host of problems (I’m talking about mostly the older kids here: irritability, hyperactivity, and learning impairment), but people don’t take heed to the problems that too much iron can cause.

    Women of childbearing age are lucky. Menstruation can help keep iron from “poisoning” the body and pregnancy usually uses up any iron “reserves.”

    There is an excellent article by Dr. Richard Kunin which you may enjoy if you are interested in learning more about iron deficiency/over-exposure: http://www.drinkyourvitamins.com/index.php?option=com_content&view=article&id=187:iron-deficiency-more-than-tired-blood&catid=53:articles-on-nutrition&Itemid=121

  10. says

    Just stumbled upon your blog! Love it! Finally more articles about the myth of iron deficiency from breastmilk. I covered the same topic a while ago on my blog accompanying my homemade cereal instructions. I hope you can take the time to check it out!

  11. Jenny says

    I love your site, Laurie!  It’s cute and informative too – I’m glad to see other folks are out there spreading the word about optimal nutrition for the little guys.

  12. Amy says

    Thank you for your post! I have an almost 7 month old EBF baby who is just not ready for solids. Our pediatrician has been pushing iron fortified cereal since his four month check up. I’m pretty confident my breast milk is sufficient nutrition (he’s almost 20 lbs of happy baby) but because of the dr’s constant doubt I needed to find some reassurance.

  13. Mich says

    Some babies really are iron deficient. Pediatricians don’t just rely on the hcg. They check several other lab values – the size and shape of the red blood cell, the total iron, developing RBC’s etc. Don’t just assume that whatever the pediatrician says is wrong – just be educated and get all the info and get all the values from the labs they check. Be informed and have an open dialogue – They want your baby to be healthy, too.

  14. Dr. Susan says

    Iron deficiency can also be a symptom of bacterial gut dysbiosis. There are lots of bad bacteria that love iron. I’d recommend a therapeutic dose of probiotics and/or probiotic foods!! Perhaps also some grapefruit seed extract, although you may want to have a stool test done with Doctors Data or Genova to check which bacteria you’re fighting.

  15. says

    With regard to the question of how evolution could have favoured iron deficiency, I think there are two important points to bear in mind:

    1. A trait will only be affected by evolution if it affects the chances of passing your genes on to the next generation. This may be by affecting reproductive abilities directly, or it may be by affecting your chances of surviving long enough to reproduce, or it may be by affecting your chances of finding an appropriate mate… but, unless a trait impacts in some way on your chances of passing your genes on, it is not going to be affected by evolution regardless of how negative a trait it may be in other ways.

    Iron deficiency has fairly subtle effects on a child’s intelligence and behaviour. I don’t think we can assume that our ancestors would have had a reduced chance of survival if iron-deficient as children. But the effects still might be something we’d prefer to avoid in our children, because we want more for our children than simply optimising their chances of staying alive long enough to reproduce themselves.

    2. Sometimes, evolution has to make trade-offs. That iron has to come from somewhere, and, since our ancestors often had to live through harsh conditions where food was scarce, it’s likely that many women would have been iron-deficient themselves and would have had less to pass on to their children. In which case, ensuring that each breastfed child goes slightly short of iron without going short enough to impair their chances of survival might actually be a positive adaptive mechanism on the part of evolution, by saving some of the limited iron resources for future offspring and thus increasing the total number of offspring a mother could keep alive.

    There are studies showing that breastfed babies are more likely to go short of iron in the months immediately before weaning, including calculations showing that this is a genuine risk for babies whose cords were clamped early (as is still far too common a practice in the Western world).

    • rpl says

      i think it would be reasonable to say that a toddler being weaned in many cases is not getting a balanced variety of nutrients and this could be a factor in the iron deficiency. personal example- when we weaned (child-led) we immediately went to diced up pieces of whatever we were eating. in the case of friends who did have this problem, they were families who regularly ‘nuked dinner’ if they were ‘cooking’ at home and fed their babies puffed treats and baby meals (you know the boxed meals that are in stages from the same company that makes the puffed treats). sadly, these are now the kids who are overweight & struggling in school.
      the whole breastfeeding issue at the realfood media sites really makes me wonder- these are not the people you need to be worried about.

  16. Laura says

    Just FYI for your readers, risk factors for iron deficiency anemia in infants are: 1) Premature cord clamping (see Dr. Alan Greene’s work on this, we should wait AT LEAST 90 seconds), 2) Prematurity (babies uptake the most iron for their stores during the last trimester of pregnancy, if they come early they miss part of that), 3) Low birth weight (separate from prematurity), anything under 3000g or roughly 6lbs 5oz makes babies more susceptible.

    My older child was a 7lb term newborn, cord clamped after it stopped pulsing (several minutes after birth), nursed exclusively for 12 months and very limited solids until 15 months. We did have blood draws to check his hemoglobin and his numbers have always been VERY robust. We eat a WAPF diet & my iron levels have always been great throughout pregnancy & even immediately after birth.

    However, we are currently dealing with anemia in my second born. He also had optimal cord clamping but he was born at 36 weeks and weighed 6# 5oz. We started baby led solids at a little after 7 months, did heal sticks for iron levels at 6 & 9 months (which were normal) but his one year bloodwork still showed moderately low hemoglobin (8.5). He is totally asymptomatic (not pale, lethargic, irritable, delayed, bruising easily, etc) & eats a great diet, but he had risk factors for anemia & it happened. So now he’s on the all liver all the time diet:-) Thank goodness he’s had it before & eagerly accepts it. We will do bloodwork again in one month to make sure it’s come up.

    I had a false sense of security because of our great diet (my kids eat liver!) and his rosy cheeks and beautiful fat rolls. But that’s why it’s important to do the bloodwork, ESPECIALLY if your child has any of the risk factors. I have been told that older infants may not have overt symptoms of anemia until it is very severe. As has been mentioned, iron deficiency at that level can cause long term negative impact on development and cognition.

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