Abstract Ref Number = APCP101
Meeting the Requirement of Iron through Complementary Feeding
Pediatrics, Division of Nutrition Metabolic Disease, CiptoMangunkusumo HospitalUniversity of Indonesia
The age interval for complementary feeding, 6 to 24months, is also the time when iron deficiency and
anemia are most prevalent.1After approximately 6 months of age, term breastfed infants are increasingly dependent on other sources of iron to avoid iron deficiency, due to the depletion of the iron stores present at birth and to the low concentration of iron in human milk.2In 2010, the global prevalence of IDA was 32.9%.3 There has been no national data regarding IDA or iron deficiency (ID) prevalence in Indonesian under-five. A small study in exclusively breastfed infants showed that iron deficiency anemia prevalence was 7.1% (4 out of 56) while iron deficiency without anemia was 3.6% (2 out of 56)at age 6 months.4A study in 300toddlers showed that iron deficiency anemia was 14.6% and iron deficiency without anemia 15%.5
Because of the rapid rate of growth during infancy, iron requirements at 6 to 12 months of age are very high,with recommended intakes set at 11 mg/day.6 At 12 to 24 months,iron requirements are lower than at 6 to 12 months,with the recommended intakes set at 7 mg/day.6 The amount of iron providedby breastmilk is relatively low, approximately 0.2 mg/day, which means that the net amount needed fromother sources is approximately 9 to 10 mg/day at 6 to 8 months and approximately 5 to 7 mg/day at 12 to 24months.
Addressing the issue of iron deficiency via complementary feeding
The richest sources of highly bioavailable iron are flesh foods (meat, poultry, and fish), particularly liver. The World Health Organization (WHO) guiding principle of complementary feeding recommended that meat, poultry, fish, or egg should be eaten daily or as often as possible.7 The European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) recommended that from the age of 6 months, all infants and toddlers should receive iron-rich (complementary) foods, including meat products and/or iron-fortified foods.1Because iron cannot be excreted from the body, intestinal absorption of iron is strictly regulated. Some food components promote non-heme iron absorption (ascorbic acid, citric acid, meat proteins, and human milk), whereas others inhibit absorption (phytates, polyphenols, calcium, and cow’s milk). Absorption of non-heme iron from breast milk is usually assumed to be upto 50% and absorption from infant formula and iron-fortified complementary foods is usually assumed to be approximately 10%8, while absorption from meat (heme iron) is assumed to be 35%.2
The estimated physiologic requirementsof absorbed iron was 0.69 mg/d for infancy.9 Assuming 35% iron absorption from meat, then 80 g of cooked, lean beef containing 2 mg of iron is needed to meet the requirement of infant. There is evidence from a study that meat intake as a first complementary food has a similar effect on iron status asiron-fortified cereals, even though the daily iron intake in the cerealgroup was approximately 5 times higher.10 This is compatible withprevious studies suggesting that iron absorption is several-foldhigher from meat than from cereals.11Meat also contributes to improve zinc status, which is another problematic micronutrient in infancy. Increased meat intake by breastfed infants >6 months old would adequately support both iron and zinc requirements.12A randomized study in exclusively breastfed infants in Jakarta showed that cooked chicken liver 70 g/day (equal to 200 g of raw chicken liver) yielded a similar effect on iron status as iron-fortified cereal.13Thus, chicken liver is an affordable and feasible option for first complementary food in low socioeconomic population.
Routine iron supplementation
Routine iron supplementation must be considered thoroughly. It is important to note that iron is a potent pro-oxidant and that iron, in contrast to most other nutrients, cannot be actively excreted by humans.8 In children, the risk of iron overload must be considered since there is evidence that iron supplementation of iron-replete infants may have adverse effects of increased risk of impaired growth.14 In a malaria-endemic population of Zanzibar, significant increases in seriousadverse events were associated with iron supplementation.15 More research is needed in populations affected by HIV and tuberculosis.
Screening for iron deficiency
World Health Organization in2016 recommended that there is no need to screen for anaemia prior to iron supplementation in settings where anaemia is highly prevalent. However, there is also remarks stated oral iron interventions should not be given to children who do not have access to malaria-prevention strategies.16 American Academy of Pediatrics (AAP) recommended universal screening for anemiashould be performed at approximately12 months of age with determinationof hemoglobin concentration and an assessment of risk factors associatedwith iron deficiency/iron deficiency anemia.17 If the Hb level is less than 11.0mg/dL at 12 months of age, then further evaluation for iron deficiency anemia is requiredto establish it as a cause of anemia.If there is a high risk of dietary iron deficiency, further testing for iron deficiency should be performed, given the potential adverseeffects on neurodevelopmental outcomes.Additional screening testsfor iron deficiency or iron deficiency anemia should include measurementofserum ferritin and CRP level.17The AAP recommendation might be costly to be performed in Indonesia and regarded as invasive to some parents. Thus, a screening tool for risk of iron deficiency in toddler (Ironcheq) was developed by Sjarif et al, which consisted of 3 questions of semi quantitative intake: (1) growing-up milk (GUM); (2) chicken/beef liver, and (3) beef. The Ironcheq validation study showed good result thus it could be used to identify children at risk of iron deficiency who needs further investigation of hemoglobin and iron profile.18
It is appropriate to tackle the issue of iron deficiency via complementary feeding interventions.All infants started from age 6 months and toddlers should receive iron-rich (complementary) foods, including meat products and/or iron-fortified foods. Liver is an affordable option of rich iron source. The absorption of non-heme iron is inhibited by phytates which is found in many staple food such as rice, maize flour, grain, corn starch, and plant protein such as soybeans, peanut, lentils. Iron supplementation in preventive programs may need to be targeted throughidentification of iron-deficient children.19