NHD PAEDIATRIC HUB FACT FILE
Infant Feeding
If your new to paediatrics or simply a student commencing a paediatric placement, it’s important to understand infant feeding. Infants need breast milk or formula to provide the protein and energy they need to grow. The amount and type of food infant eats changes as they grow. This is a simply a brief guide to help you navigate this area.
Breastmilk
Breast milk is a living fluid produced by a mother's mammary glands that provides essential nutrients for a baby's growth and development. It's the primary source of nutrition for new-borns. It contains:
Water: About 87% of breast milk is water
Fat: The fat content varies throughout the day and during a feeding
Protein: Breast milk contains proteins
Carbohydrates: Breast milk contains lactose
Minerals and vitamins: Breast milk contains minerals and vitamins
Hormones: Breast milk contains hormones that regulate metabolism and appetite
Growth factors: Breast milk contains growth factors
Immunological factors: Breast milk contains factors that protect against infection and inflammation
Breastmilk changes throughout a mother’s breastfeeding journey:
Colostrum: The first milk produced after pregnancy is thick and yellow, and rich in immune factors
Transitional milk: A combination of colostrum and mature milk that's produced from days 7 to 14 after pregnancy
Mature milk: Produced after about 10 to 15 days, mature milk contains all the nutrients a baby needs
The fat content of the breast milk also changes throughout the day and during feeds which shows how adaptable it is as a source of nutrition.
Breastfeeding also carries many advantages for babies outside of just growth...
Benefits of breastfeeding
Protection
Breast milk contains antibodies that help babies develop a strong immune system.
Breastfed babies have a lower risk of many illnesses, including asthma, obesity, type 1 diabetes, and SIDS.
Breastfed babies are less likely to have ear infections and stomach bugs.
Brain development
Breast milk contains DHA and ARA, which help a baby's brain and visual system develop.
Breastfed babies may perform better on intelligence tests.
Other benefits
Breastfeeding can support the mother-baby relationship.
Breastfeeding can be convenient for mothers.
Breastfeeding can be comforting for babies when traveling.
It can be difficult to measure what influences there is on development and learning of children as lots of factors do influence this. However, some studies do show that breastfed babies and societies where more babies are breastfed, do better overall.
Let’s not forget that the mother also gets breastfeeding benefits. They have a lower risk of breast cancer, ovarian cancer, osteoporosis, cardiovascular disease and obesity.
Risk factors
Infants:
- Maternal iron deficiency
- Prematurity or/and low birth weight
- Late or insufficient introduction of iron-rich solids
- Excessive cow’s milk
Children and Adolescents:
Vegan or vegetarian diet
Gastrointestinal disorders like coeliac disease, intestinal surgery and IBD
Other chronic blood loss
Athletic populations
Females with heavy menstrual bleeding
Symptoms of iron deficiency
Cognitive impairments:
Decreased memory, concentration and learning abilities
Physical symptoms:
Fatigue, pale skin, loss of appetite, pica and growth delays
Behavioural issues:
Increased irritability and decreased attention span
Other symptoms:
Decreased immunity, sleep disturbances, brittle hair/nails and fast heartbeat
Assessment
Causes of iron deficiency are wide ranging, but it’s important to detect the cause in the initial assessment. Possible causes include the following:
Depletion of iron stores in the second half of infancy occurs when the iron content of the weaning diet is poor, even though deficiency may not be evident until 12 months of age.
The early introduction of cow’s milk as a main drink before 12 months of age can be a contributing factor, hence there is reason to consider whether the WHO's recent update on complementary feeding should be applied to the UK.
Availability and choice of baby foods may also contribute to iron deficiency, especially for Muslim families where there is a limited range of halal meat-based products.
An overdependence on milk (consuming more than 400mls/day) in toddlers and preschool children, is a factor, where it replaces iron-rich foods.
In older children, deficiency occurs most commonly in teenage girls who have commenced menstruation and have higher iron requirements, and also in children who are vegetarian or vegan and are struggling to follow a balanced diet.
Screening and diagnosis
Full blood count (FBC): Key for diagnosing anaemia by evaluating haemoglobin levels. Anaemia is defined as an Hb level two standard deviations below the normal for age and sex.(3) In children aged 12-14 years, this is below 120g/L. For women over 15 years it's 120g/L and men over 15 it's Hb below 130g/L.
2. Serum ferritin: Most reliable for assessing iron stores, with <30 μg/L indicating low iron. This can confirm the diagnosis of iron deficency. However, there are some caveats to this, for example, if infection or inflammation is present, levels can be high even with iron deficiency.(3)
Treatment
It’s important that the medical team investigate any other underlying causes of anaemia, but these investigations should not delay the starting of treatment.(4)
MEDICAL TREATMENT
Iron supplementation: Ferrous fumarate, gluconate, sulfate, or sodium feredetate are commonly prescribed. Dosage and duration depend on the severity of deficiency and the patient’s response to treatment.
Please note that iron supplementation may also be required to produce an optimum response to erythropoietin in iron-deficient children with chronic renal failure, or preterm neonates.(4)
Monitoring: Iron levels are reassessed two to four weeks after starting supplementation, and treatment continues for three months after correction.
Iron levels usually return to normal within one to two months. However, if there is no response to supplementation, then a referral to a specialist medical team will be made.
If responding well, this treatment is usually continued for three months after the iron deficiency is corrected to ensure blood levels remain stable and build up the store of iron in the body.(3)
Some of the common side effects of these medications include black stool, constipation, gastrointestinal discomfort and nausea.(4)
Iron can be administered parenterally but is reserved for use when oral therapy is unsuccessful because the child cannot tolerate oral iron or does not take it reliably, or if there is continuing blood loss and in malabsorption.(4)
DIETETIC TREATMENT
Dietitians should promote the following:
Iron-rich foods: Include red meats, dark poultry, fish, eggs, legumes and fortified cereals.
Enhancing absorption: Vitamin C-rich foods (like citrus fruits) should be consumed with iron-rich meals.
Avoid inhibitors: Tea, coffee and excessive dairy during meals can hinder iron absorption.
Iron-rich meals to suggest:
Spaghetti Bolognese
Shepard’s pie
Baked beans on toast
Kidney bean chilli with rice
Iron-fortified cereals or porridge with fruit or a glass of fresh orange juice
Iron-rich snacks to suggest:
Hummus with breadsticks and vegetable crudites
Trail mix of dried figs or apricots with mixed nuts (please note that this should only be suggested to children over the age of five)
Peanut butter on rice cakes or crackers
Hard boiled eggs
Roasted chickpeas
** Fortified foods and gluten-free fortified foods Database Table **
Want to know more about fortified products in iron and calcium (including gluten-free products)? We have released a brand-new database for this! Some foods may surprise you...
Recent research in this area...
Berger MM, Shenkin A. Micronutrient deficiency and supplements in schoolchildren and teenagers. Curr Opin Clin Nutr Metab Care. 2024 May 1;27(3):266-274. doi: 10.1097/MCO.0000000000001027. Epub 2024 Mar 8. PMID: 38462972
Gruda Sussman R, Baker JM. An urgent appeal to paediatric primary caregivers to help prevent severe iron deficiency anaemia in toddlers. Paediatr Child Health. 2023 Mar 22;29(4):209-210. doi: 10.1093/pch/pxac089. PMID: 39045470; PMCID: PMC11261818
Svensson L, Chmielewski G, Czyzewska E, Domellöf M, Konarska Z, Piescik-Lech M, Späth C, Szajewska H, Chmielewska A. Effect of low-dose iron supplementation on early development in breastfed infants: A randomised clinical trial. JAMA Pediatr. 2024 Jul 1;178(7):649-656. doi:10.1001/jamapediatrics.2024.1095. PMID: 38739382; PMCID: PMC11091819
Perera DN, Palliyaguruge CL, Eapasinghe DD, Liyanage DM, Seneviratne RACH, Demini SMD, Jayasinghe JASM, Faizan M, Rajagopalan U, Galhena BP, Hays H, Senathilake K, Tennekoon KH, Samarakoon SR. Factors affecting iron absorption and the role of fortification in enhancing iron levels. Nutr Bull. 2023 Dec;48(4):442-457. doi: 10.1111/nbu.12643. Epub 2023 Nov 15. PMID: 37965925
da Silva Lopes K, Yamaji N, Rahman MO, Suto M, Takemoto Y, Garcia-Casal MN, Ota E. Nutrition-specific interventions for preventing and controlling anaemia throughout the life cycle: an overview of systematic reviews. Cochrane Database Syst Rev. 2021 Sep 26;9(9):CD013092. doi:10.1002/14651858.CD013092.pub2. PMID: 34564844; PMCID: PMC8464655
Compiled exclusively for NHD by...
Fact file references
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4462328/
- National Diet and Nutrition Survey (publishing.service.gov.uk)
- https://cks.nice.org.uk/topics/anaemia-iron-deficiency/
- https://bnfc.nice.org.uk/treatment-summaries/anaemia-iron-deficiency/