Dear all:

The one area that I totally freaked out about during the exams was all the
nutrients in breast milk and how these relate to moms diet.  All nutrients
are not created equal.  For nutrients such as vitamin C, there is a
protective effect where you cannot get a higher concentration of vitamin C
in the milk even if mom has totally overdosed herself - there is a
plateau.  There are other nutrients where there is a floor, below which mom
will sacrifice her own stores.  Then there are nutrients like iodine that
tend to reflect moms stores and intake fairly closely.

Having worked in developing countries on micronutrient programs (primarily
vitamin A, iron & iodine), I can tell you that mom's iron status does not
make much difference to the concentration of iron in breast milk.  The
concentration in breast milk is relatively constant.  Supplementing mom is
not going to increase the iron in the breast milk, just as an iron
deficient mother is still generally going to have enough iron in her breast
milk.

Moreover, even if we could stuff enough iron into a mom to make a
difference in the iron in her milk (which we can't), a two year old clearly
needs iron from another source than just breast milk.  Kay Dewey did a
marvelous presentation at the American Academy of Breastfeeding Medicine in
2003 where she talked about the two nutrients that are needed in the
highest quantities when infants are first introduced to solids.  Those
nutrients are iron and zinc.

Iron is important for cognitive development.  Irreversible delays can occur
even if an infant is just iron deficient, without getting to the later
stage of iron deficiency when anemia occurs.  We all know the infant that
is entirely breastfed to 12 months and is perfectly fine with no signs of
anemia or cognitive delays, just like we know the smoker that lives to 80
years old (but probably isn't really just fine even though they managed to
live that long).  The problem is that there is no way to know for a
particular infant without the possibility that they will suffer the
consequences.

The HemoCue test that I find is commonly used in pediatricians offices is a
test that I am intimately familiar with.  This is a test that we used in
developing countries to monitor changes in response to various iron
programs at a population level.  This test was heavily criticized by the
International Iron Deficiency Anemia Consultative Group because of its
imprecision.  Precision matters even more when looking at individual
cases.  I have a whole list of mistakes that a health care practitioner can
make that will throw this test off.  I have observed all of these errors in
my pediatrician's office.  It is a CRUDE test.  Ditto the hematocrit. And
neither of these tests pick up on iron status itself. So, this poses a
problem because the so-called "gold standard" tests that test iron status,
not just anemia are highly invasive.  I have ethical questions about using
these tests on an infant because they generally require a venous sample.  I
don't think its worth it.

I think there is enough evidence that infants need additional iron at six
months of age that we should be helping moms find acceptable forms of this
nutrient whether they are vegans or carnivores.

Zinc is important for immune function and appetite.  An infant that is
anemic may also be deficient in zinc because the food sources are similar.
The tests for zinc are even more flawed than those for iron.

So, I'd try to look for good sources of iron and zinc that are palatable to
this child and/or supplement with these nutrients.

Best,

Susan Burger, MHS, PhD, IBCLC

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