What are the American Academy of Pediatrics (AAP) guidelines for vitamin D and iron supplementation in infants?

AAP Guidelines for Vitamin D and Iron Supplementation in Infants

All infants consuming less than 28 ounces of commercial infant formula per day should receive 400 IU per day of vitamin D supplementation, beginning at hospital discharge and throughout breastfeeding, and breastfed infants who receive insufficient iron from complementary foods by age 6 months should receive 1 mg/kg per day of iron supplementation. 1

Vitamin D Supplementation Guidelines

Recommendations for Vitamin D

• Exclusively or partially breastfed infants: 400 IU/day of vitamin D starting at hospital discharge 1
• Formula-fed infants: 400 IU/day of vitamin D if consuming less than 28 ounces of formula daily 1
• Duration: Throughout the entire breastfeeding period and first year of life 1, 2

Rationale for Vitamin D Supplementation

• Vitamin D deficiency and rickets have increased in all infants due to:
  • Decreased sunlight exposure
  • Changes in lifestyle and dress habits
  • Use of topical sunscreen preparations 1
• Breast milk alone typically contains insufficient vitamin D to prevent deficiency
• Adequate vitamin D is essential for bone health and calcium/phosphate regulation 3

Alternative Approach

• An alternative strategy is maternal supplementation with 6400 IU of vitamin D daily, which can increase breast milk vitamin D content 1
• However, direct infant supplementation remains the standard recommendation due to safety concerns with high-dose maternal supplementation 3

Iron Supplementation Guidelines

Recommendations for Iron

• Exclusively breastfed term infants: 1 mg/kg/day of iron drops if receiving insufficient iron from complementary foods by 6 months of age 1
• Preterm or low birth weight breastfed infants: 2-4 mg/kg/day of iron drops (maximum 15 mg/day) starting at 1 month after birth until 12 months 1
• Formula-fed infants: Only iron-fortified formula should be used for infants under 12 months 1

Complementary Foods and Iron

• Introduce iron-fortified infant cereal at 4-6 months (2+ servings daily can meet iron requirements) 1
• By approximately 6 months, include one daily serving of vitamin C-rich foods to improve iron absorption 1
• Introduce pureed meats after 6 months as they are excellent sources of iron 1
• Avoid cow's milk, goat's milk, and soy milk until 12 months of age 1

Implementation Considerations

Monitoring

• Screen high-risk infants for iron deficiency anemia between 9-12 months of age 1
• For infants not at high risk, screen selectively based on risk factors (preterm birth, non-iron-fortified formula, early cow's milk introduction, etc.) 1
• Monitor vitamin D status in patients receiving long-term parenteral nutrition 1

Common Pitfalls to Avoid

1. Poor adherence: Studies show that only 5-13% of exclusively breastfed infants and 20-37% of formula-fed infants receive adequate vitamin D supplementation 4
2. Delayed initiation: Supplementation should begin at hospital discharge, not weeks or months later 1
3. Inadequate dosing: The 2008 AAP recommendation doubled the previous vitamin D recommendation from 200 IU to 400 IU daily 2
4. Stopping too early: Supplementation should continue throughout the first year of life 1
5. Assuming formula provides enough: Formula-fed infants consuming less than 28 oz/day still need vitamin D supplements 1

Special Populations

• Preterm infants: Require both multivitamin preparation and oral iron supplement until consuming a complete mixed diet with normalized growth and hematologic status 1
• Infants with dark skin: May be at higher risk for vitamin D deficiency and require the same supplementation 3

By following these evidence-based AAP guidelines for vitamin D and iron supplementation, healthcare providers can help prevent deficiencies that could negatively impact infant growth, development, and overall health outcomes.