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From:
Susan Burger <[log in to unmask]>
Reply To:
Lactation Information and Discussion <[log in to unmask]>
Date:
Sat, 5 Nov 2011 11:15:39 -0400
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Dear all:

As much as I vociferously object to unwarranted use of supplementation as a blanket recommendation, I also think it is important to understand that there are times when it is clearly warranted.  Iron deficiency BEFORE ANEMIA occurs is very important for cognitive development.  And in this case, there is evidence to suggest irreversible delays -- not something that I personally would be comfortable tinkering with.

Just like babies were supposed to get vitamin D from conversion of sunlight on their skin, babies were supposed to get iron from stores that build up during the last trimester of pregnancy.  In both cases we have environmental issues that may interfere with absorption.

Here are some of the issues that may lead to a baby not having the full iron stores they were supposed to have for the first six months of life:

1) Prematurity - insufficient womb time
2) Premature cord clamping
3) Use of formula (which interferes with iron absorption)

Any one of those items might tip the balance and contribute to iron deficiency before six months of age.  From my read of the study that was quoted on Lactnet a while back that was used for justification among exclusively breast-fed infants -- the research supported that some of the MIXED fed infants did indeed an additional source of iron before six months.  It was not clear from the research whether or not exclusively FULL-term breastfed infants needed the iron because they did not define exclusivity well enough.  

As you can see: 1) and 2) are highly dependent upon obstetrical practices. So the environmental problem is that many babies are subjected to obstetrical practices which interfere with iron stores.

In a highly interventionist environment, I would not be so cavalier on an individual basis as to discount the possibility that iron stores are low.  Just like I would explain to a mother that low vitamin D stores has NOTHING to do with breast milk, I would explain to a mother that iron stores had NOTHING to do with breast-milk either.  On and INDIVIDUAL basis, I would explore these issues carefully.  What was the baby's gestational age?  Was the cord prematurely clamped?  

Here is where the dilemma lies -- does one start complementary foods rich in iron early? or use a highly processed concentrated form of iron?      

And after a long discussion with my dissertation advisor (who is such an independent cuss that he cannot be swayed by opinion based anything and drives everyone to despair when he manages to take appear their favorite opinions), I was privy to the sources of the controversy over introduction between four and six months of age.  It is a dispute that was hotly debated between WHO (which wanted the range) and UNICEF (which wanted one number).  The research is abundantly clear that it INCREASES risks of diarrhea to introduce complementary foods before six months in areas where water is contaminated and sanitation is poor.  There is no clear-cut risk when water is potable and sanitation are good. At the same time there is no clear-cut evidence of the benefits of introducing solid before 6 months either.  It is entirely squishy territory and is likely to be subject to debate for a long time to come.  As any of you who have read my posts on Lactnet, I err on the six of exclusive to six months.  

Nevertheless, I would adopt a more pragmatic approach to any baby that shows risk of iron deficiency anemia.  What strikes me as nonsensical is disrupting breastfeeding on the presumption that doses of iron that are meant to ensure that all babies get enough even those who have already had their iron absorption disrupted by formula.  The small amounts lost are unlikely to matter compared to the disruption of breastfeeding.

Best regards, 

Susan Burger


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