Breastfeeding and Iron

I recently wrote a guest post about breastfeeding for a friend's blog, which actually didn't generate too much conversation, which might be due to the fact that the first post on breastfeeding spawned a huge 90+ comment thread on my friend's facebook wall and I think people were bowing out of the conversation by the time I entered it. He asked me to contribute because people kept bringing up the Middle East as an example, though none of them had ever been there.

For the most part, I feel like I've been supported through my breastfeeding years but that might have changed this past week.

"How long do you plan on breastfeeding him?" our pediatrician asked.

"Oh, however long he wants," I told her.

"How long did you breastfeed your other children?" she asked.

"About 18 months for Rachel and nearly two years for Miriam."

"Oh! Well, you don't have to do that, you know," she told me as if she was letting me in on a little secret. "You can wean him onto whole milk at 12 months."

I stared at her and blinked my eyes, unsure of what to say next. It was she who broke the awkward silence by stammering, "But of course 'breast is best.' You just can introduce whole milk at 12 months."

Sometimes I don't say anything when I should say something. Other times I say things when I ought not. Even other times I don't explain myself well enough.

Communication is a bear.


She didn't seem satisfied in his solid food intake at our last appointment (because he was only 6 months old and we hadn't begun solids...like at all) and suggested that we either begin an iron-fortified cereal or start giving Benjamin a multi-vitamin + iron supplement, which, for the record, we did. We started him on rice cereal and then added applesauce. We tried carrots, which he spat up everywhere all day long. We decided to stick with clearer stuff, so tried pears next. He's tried Cheerios. But he still spits up a lot, so we're taking things rather slow. He's interested in eating, but not terribly so, and sometimes insists on nursing rather than eating...

I explained that all to the doctor and finished with, "But he eats something everyday."

We're working on the solid thing, really we are. But...

"He only eats solids once a day?!" our doctor balked. "He should be getting at least two servings of iron-fortified cereal a day and I'm going to suggest an iron supplement as well."

I understand that iron is important for development. I understand that babies' stores of iron get used up by around 6 months of age and that supplementation is needed thereafter. What I don't get is why it's assumed that all breastfed babies need supplementation, specifically in the form of prescribed droplets, when food can be a perfectly good source of iron.

For the record, our "take-home" material states that a serving, for a boy Benjamin's age, is only 1/2 to 1 tablespoon of solid food. He might eat but once (rarely twice) a day but I assure you he's eating more than a couple of tablespoons (I measured today and...yup, he probably eats three or four tablespoons before he starts slowing down. So, that's more than a single serving, at least according to our take-home papers. And, sure, he could use some more variety in his diet.

But I still think the suggestion that every breastfed child take an iron supplement is a little odd.

Benjamin wasn't a full-term baby, but our doctor hardly seems to register that fact when she looks at his growth or development. And she didn't mention in in our discussion of nutrition and iron, either.

It's likely his iron stores weren't quite up to par with a full-term baby. But, on the other hand, I make milk and lots of it. It's a blessing and a curse, I assure you (but mostly a blessing).

Yesterday, I was reading a post on my friend Crystal's blog and at the bottom it suggested I read her "preemie: day four" post so I clicked on over and saw that it was about pumping. Oh, pumping...how I do not miss you! She had taken a picture of a syringe full of colostrum. I remember triumphantly documenting my first syringe of colostrum as well—as if celebrating my ability to lactate somehow compensated for my inability to do anything else for my baby—and was curious about how much milk I was making during my story of "preemie: day four," and, holy cow! So much of the milk.

By four days, I was already getting over a liter of...stuff...per day. It didn't qualify as milk yet and was still "yellow dot" worthy, which meant it was colostrum-ish. We'll call it colostro-milk.

So I remarked about how much colostro-milk I'd been making then, remarking that when my milk-milk comes in it's super fatty, so I was pretty sure Benjamin was well-nourished, but that after getting my friend Sam's comment about her baby not sleeping well due to anemia and Crystal's own comment about preemies not having as much iron stored up, and her husband's insistence that she feed their baby iron (he's a doctor), that I'd redoubled my efforts to feed Benjamin iron-rich sustenance.

She replied that it's not about the quality or quantity of the milk; it's about the iron.

(And I maybe think that I might have slightly offended her but I didn't mean to and I'm not sure if I did because I couldn't quite tell from her written tone; so I'm sorry if I did. I'm just genuinely curious about this now that it's come up because it's never been an issue brought to my attention before.)

A good point she made, too, because breast milk is low in iron (and also vitamin D). There's no arguing against that. However, colostrum has about 48% more iron than mature milk (1 mg/L compared to .70 mg/L) so I hypothesize that my baby may have gotten a little higher dose of easily absorbable iron than other NICU babies since he continued to receive colostrum for quite a while after my milk had come in.

I promise that I feed my baby iron-fortified cereal. But I still wonder about those vitamin drops. And how we ever survived without them. And why the UK doesn't seem to routinely recommend them (while in the United States they do).

There's much to be found on this topic online (or "on the line" as Miriam likes to call it), from people claiming that since we don't allow our children to play in the dirt like cavemen we need to give supplements. Admittedly, the author of this article is at least talking about food (which is practical). And I'm sure I came across several of the scary articles she came across, too, talking about the problems iron-deficiency can cause for our young ones.

Diet is great, and I'm sure Benjamin's could be better, but I'm still not convinced that direct supplementation is the answer.

After reading a few more bloggy-type things (this, this, this, among many others) I decided that what I really wanted was not bloggy-type things. Because I write a blog and a lot of what I say is just my opinion...imagine that. So I sought out some more in depth studies.

This one concluded that at around 9 months of age, infants adapt to a low-iron diet and actually begin absorbing more iron from foods (including straight breast milk) compared to 6 month old infants. However, that didn't mean that being 100% breastfed was necessarily healthy for a baby at 9 months old (just that their body would begin to compensate for a low-iron diet at that age, similarly to how an adult body would function). My favourite part was when they said that 7 of 43 "test meals" were refused when they were offered in bottles...so the poor babies were fed "by nasogastric tube in those instances."

You don't want the bottle? We'll cram it down your throat.

I dunno...Benjamin never seemed too fond of his NG tube and pulled it out so many times so I kind of feel sorry for those babies, though I'm sure NG tubes don't technically hurt. But what if the babies simply weren't hungry?

All for the sake of science, I guess.

This other study concluded that

universal daily iron supplementation of breast-fed infants may present risks for those with normal Hb, who may be a large proportion of the population, even in low income countries. Although targeting is costly and sometimes impractical, it may be a safer option in such situations. Alternatively, less frequent administration of iron supplements (e.g., weekly) may reduce the likelihood of potentially adverse effects.  

This is completely in line with what was found to be the case with anemic pregnant women in this study.

Basically I learned that the effects of iron-deficiency are far-reaching, but so are the effects of too much iron, so it's probably best to modify your diet (or your baby's diet) to make sure there's plenty of iron-rich food available for your body to absorb iron from (and foods high in Vitamin C and magnesium (and so forth) to help aid the absorption of said iron) rather than simply buying an iron supplement.

Of course, if you're absolutely positive you're anemic, you might need a little extra help. However, we're not absolutely positive Benjamin's anemic, or even iron-deficient—he hasn't had a blood test since we lived in Utah and we left over six months ago—so to assume he's not getting enough iron in his diet from one conversation seems rash and to suggest that he needs iron drops seems even more bizarre when we should attempt to control his iron levels with food first (and since he's getting iron-fortified cereal that counts for something).