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ABM Clinical Protocol #29: Iron, Zinc, and Vitamin D Supplementation During Breastfeeding
Abstract
A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols, free from commercial interest or influence, for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient .
HUMAN MILK is designed to deliver comprehensive nutrition through the first 6 months of age and complementary nutrition through the early years. However, micronutrient supplementation may be appropriate, especially when a mother is deficient or an infant has special needs such as prematurity. In contemporary high- and low-resource settings, concern has been raised regarding iron, zinc, and vitamin D status of human milk-fed infants. This protocol reviews the available evidence regarding iron, zinc, and vitamin D supplementation of the breastfeeding dyad. 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. From currently available evidence, recommendations are provided and areas for future study are identified. A brief summary of recommendations is presented first, followed by more in-depth discussion of the three micronutrients.
Recommendations
Iron
Iron supplementation is not required for the non-anemic breastfeeding mother. Iron supplementation to the 4-month-old 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. (LOE IB)
Zinc
Zinc supplementation, above dietary intake, to the lactating mother or breastfeeding infant is not associated with improved outcomes and, therefore, is not recommended. (LOE IB)
Vitamin D
The breastfeeding infant should receive vitamin D supplementation shortly after birth in doses of 10–20 μ g/day (400–800 IU/day) (LOE IB). This supplement should be cholecalciferol, vitamin D 3 , because of superior absorption unless a vegetable source such as ergocaliferol vitamin D 2 , is desired (LOE IIA). 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 μ g/day (6,400 IU/day) is suggested.
Iron
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