AAP Guidelines for Iron and Vitamin D Supplementation in Infants
According to the American Academy of Pediatrics (AAP), all infants consuming less than 28 ounces of commercial infant formula per day should receive 400 IU of vitamin D daily, and breastfed infants who receive insufficient iron from complementary foods by 6 months of age should receive 1 mg/kg/day of iron supplementation. 1
Vitamin D Supplementation Guidelines
Who Needs Vitamin D Supplements
- All exclusively breastfed infants: 400 IU daily starting at hospital discharge 1
- Partially breastfed infants: 400 IU daily if consuming less than 28 oz of formula per day 1
- Formula-fed infants: No supplementation needed if consuming ≥28 oz of vitamin D-fortified formula daily 1
Timing and Duration
- Begin supplementation at hospital discharge 1
- Continue throughout the entire breastfeeding period 1
- For formula-fed infants, supplement only if formula intake is insufficient to provide 400 IU daily
Special Considerations
- An alternative approach is maternal supplementation with 6400 IU of vitamin D daily, which provides adequate vitamin D to the breastfed infant through breast milk 1
- For preterm infants, higher doses (200-1000 IU/day or 80-400 IU/kg/day) may be required 1
- Studies show that 400 IU/day may be insufficient, with one trial showing that 800 IU/day resulted in 50% reduction in vitamin D insufficiency compared to 400 IU/day 2
Iron Supplementation Guidelines
Who Needs Iron Supplements
- Exclusively breastfed term infants: 1 mg/kg/day starting at 6 months if insufficient iron from complementary foods 1
- Preterm or low birth weight breastfed infants: 2-4 mg/kg/day (maximum 15 mg/day) starting at 1 month of age until 12 months 1
- Formula-fed infants: No supplementation needed if consuming iron-fortified formula 1
Timing and Duration
- For term breastfed infants: Begin at 6 months if complementary foods provide insufficient iron
- For preterm/low birth weight infants: Begin at 1 month and continue until 12 months 1
- Preterm infants should receive both multivitamin preparation and oral iron supplement until consuming a complete mixed diet 1
Dietary Recommendations
- Introduce iron-fortified infant cereal at 4-6 months (2+ servings/day) 1
- Include vitamin C-rich foods with meals by 6 months to improve iron absorption 1
- Introduce pureed meats after 6 months 1
- Avoid cow's milk, goat's milk, and soy milk until 12 months 1
- Limit milk consumption to no more than 24 oz daily for children aged 1-5 years 1
Screening Recommendations for Iron Deficiency
Universal Screening
- Screen all high-risk infants (low-income, WIC-eligible, migrants, refugees) for anemia between 9-12 months, 6 months later, and annually from ages 2-5 years 1
Selective Screening
- For infants not at high risk, screen only those with specific risk factors:
- Preterm or low birth weight infants
- Infants fed non-iron-fortified formula >2 months
- Infants introduced to cow's milk before 12 months
- Breastfed infants with inadequate iron intake after 6 months
- Children consuming >24 oz daily of cow's milk
- Children with special healthcare needs 1
Common Pitfalls and Caveats
Inadequate supplementation: Studies show that only 5-13% of exclusively breastfed infants and 9-14% of mixed-fed infants receive adequate vitamin D supplementation 3
Delayed initiation: Vitamin D supplementation should begin at hospital discharge, not weeks or months later 1
Stopping too early: Supplementation should continue throughout the entire breastfeeding period 1
Incorrect dosing: Oral vitamin D is well-tolerated at recommended doses; higher doses don't add benefits but may cause toxicity 4
Relying on sunlight exposure: While sunlight provides vitamin D, the AAP recommends keeping infants out of direct sunlight, making supplementation necessary 5
Inadequate monitoring: For preterm infants, especially ELBW infants, vitamin D levels may need monitoring as they may lag behind in reaching sufficient levels despite supplementation 6