Monday,18 December, 2017
Current issue | Issue 1140, 21 - 27 March 2013
Monday,18 December, 2017
Issue 1140, 21 - 27 March 2013

Ahram Weekly

Ensuring an iron-clad infancy

Ekhard Ziegler, MD, is professor of paediatrics at the University of Iowa and a trained paediatric nutritionist. As a neonatology practitioner,
his main area of interest is premature infant nutrition. He spoke to Nesmahar Sayed on the critical role iron plays in an infant’s life

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Al-Ahram Weekly

Professor Ekhard Ziegler believes infants can be at risk of iron deficiency, which can be identified at one month of age by measuring the signs of iron endowment. If iron endowment is low due to genetic factors, then the baby is at high risk of iron deficiency. The mother’s iron intake has no influence on the iron concentration in her milk, which is always low. The baby receives an iron endowment from the mother before birth and it is usually sufficient for the baby’s first six months. However, when this endowment is small, the baby is at risk of iron deficiency at four or five months of age. All babies, Ziegler points out, must receive iron from other sources after the first five months of life because breast milk is very low in iron and does not provide the amount of iron that the baby needs. In the United States, as in many other countries, baby cereals are iron-fortified and are usually the first food the baby eats.
Premature babies, by virtue of having been born prematurely, are born with a small iron endowment. That means they run out of iron sooner than full term babies. In addition, many premature babies lose blood because they have blood drawn for laboratory testing. Their iron endowment lasts them about three or four weeks, after which they can run out of iron. Therefore, iron supplementation is essential for these babies. If the baby receives breast milk, then we add iron to the milk at a quantity of two milligrammes per kilogramme of weight. If the baby receives formula, then it might not be necessary to supplement iron as most formulae are iron-fortified. When the baby goes home from the hospital, we always make sure that the baby receives iron, either an iron supplement if the baby is breast-fed or we give advice on which formula contains iron.
Iron deficiency has a deleterious effect on the body. In adults, it leads to low energy levels. In the infant, iron deficiency can be detrimental to brain development. If the deficiency is high, the damage is usually irreversible, which is why iron deficiency prevention is of utmost importance at this age. Diminished intelligence, behaviour changes and poor brain function are some of the life-long effects. Now we know that protein intake in the first week of life can also affect intelligence later in life. So even though iron deficiency cannot occur as early as the first week of life, protein deficiency may occur at this time, which must be taken into consideration.
There is a role for mothers to play in recognising iron deficiency and to take certain positive action. Only a laboratory test can identify iron deficiency. The most common test is one that measures hemoglobin to determine whether the baby has anaemia. The only problem with that is anaemia points to severe iron deficiency and, ideally, the mother would like to protect against iron deficiency before it becomes severe. Other tests, such as serum ferritin, are better measures of iron deficiency, but they are not widely available. So the best thing the mother can do is to make sure the baby receives some extra iron every day. And, as I said, after four or five months, the iron has to come from food because breast milk is then an insufficient source. A mother needs to be sure that the baby is given fortified iron cereals, an iron supplement or some meat. It is best to give a mix of different foods. Meat is an excellent source of highly available iron and that is the best she can do.
In the US, professor Ziegler says, “we believe that it is almost impossible for breast-fed babies to avoid iron deficiency without the use of fortified iron.” The second best food is meat, especially red meat, which has the highest concentration of iron in a bioavailable form. “We strongly recommend red meat but many babies do not like meat. So the alternative is iron drops, which is safe and easily absorbed,” he said.
Theoretically, we would think that if mothers used natural foods that contain substantial amounts of iron, such as spinach, then no supplementation would be needed. But we do not know how available spinach is to the baby, so would we want to risk it? In practice, it is very difficult to provide enough iron from natural foods without the use of iron-fortified foods.
Based on his research, professor Ziegler thinks that all babies should have a serum ferritin test at two months of age, so that those at high risk can be given iron drops for at least some time until they receive complementary foods.
There are also some foods that we would be wise to steer clear from, such as cow milk. Cow milk is harmful to infants, he said. It has been shown that cow milk given to infants up to two years of age leads to iron deficiency. “And therefore, we recommend strongly against feeding cow milk in the first year of life. Perhaps one of the reasons why Egypt has a high occurrence of iron deficiency in infants is because both buffalo and cow milk are used in feeding babies,” he said.
For toddlers, the peak incidence of iron deficiency over all is about 18 months. So after the first birthday, the baby is not immune to iron deficiency and the reason generally is that toddlers are still growing very fast and have a high requirement for iron. At the same time, the food the toddler eats often supplies limited iron because toddlers do not generally like to eat much meat. So toddlers are still at risk of iron deficiency but the risk of a permanent effect on the brain is much reduced in the toddler compared to the infant. In the second year of life, they can still be iron deficient, but by year two, the brain is better developed and the child is not as vulnerable to the effects of iron deficiency.

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