What is the recommended iron formulation and dosage for breastfeeding women?

Iron Supplementation During Breastfeeding

For breastfeeding women without anemia, routine iron supplementation should be stopped at delivery, and no specific iron formulation or dose is recommended during lactation unless risk factors for postpartum anemia are present. 1

Risk-Based Approach to Iron Supplementation

Screen for anemia at 4-6 weeks postpartum only if risk factors are present:

• Anemia that continued through the third trimester 1
• Excessive blood loss during delivery 1
• Multiple birth 1

If no risk factors exist, discontinue supplemental iron at delivery. 1

Treatment When Anemia Is Identified

For breastfeeding women diagnosed with iron deficiency anemia, prescribe 60-120 mg of elemental iron daily using oral ferrous salts (ferrous sulfate, ferrous fumarate, or ferrous gluconate). 1, 2

Optimal Dosing Strategy

The most recent high-quality evidence suggests alternate-day dosing maximizes absorption while minimizing side effects:

• Give 60-120 mg elemental iron on alternate days rather than daily 3
• Administer as a single morning dose, not divided throughout the day 3
• Oral iron doses ≥60 mg stimulate hepcidin elevation that persists 24 hours, reducing absorption of subsequent doses 3
• Alternate-day dosing increases fractional iron absorption and may reduce gastrointestinal side effects 3

Iron Formulation Selection

Ferrous bisglycinate (25 mg elemental iron) has the most favorable gastrointestinal side effect profile, though ferrous fumarate (40 mg) and ferrous sulfate (50 mg) are equally effective alternatives. 4

• All three formulations prevent iron deficiency effectively 4
• Ferrous bisglycinate causes fewer GI complaints (nausea, constipation, epigastric pain) and less frequent black stools (8% vs 22-31%) compared to ferrous fumarate or ferrous sulfate 4
• If using ferrous gluconate, each 324 mg tablet provides 38 mg elemental iron 5

Monitoring and Duration

Recheck hemoglobin after 4 weeks of treatment; expect an increase of ≥1 g/dL. 1, 2

• If hemoglobin fails to increase by 1 g/dL despite compliance and absence of acute illness, perform additional testing including MCV, RDW, and serum ferritin 1
• In women of African, Mediterranean, or Southeast Asian ancestry, consider thalassemia minor or sickle cell trait if anemia is unresponsive to iron 1
• Continue treatment for 2-3 months after hemoglobin normalizes to replenish iron stores 1, 2

Dietary Counseling

Counsel breastfeeding women about iron-rich foods and factors that enhance absorption:

• WHO guidelines recommend that women in the postnatal period maintain a balanced diet and drink sufficient clean water 1
• Iron and folic acid supplementation should continue for 3 months after birth only if initiated during pregnancy for treatment purposes 1

Common Pitfalls to Avoid

• Do not routinely supplement iron in breastfeeding women without documented anemia or risk factors 1
• Avoid prescribing doses >120 mg daily, as higher doses do not improve outcomes and increase side effects 6
• Do not give iron doses in the afternoon or evening after a morning dose, as circadian hepcidin elevation reduces absorption 3
• Ensure calcium supplements and antacids are taken at different times, as they decrease iron absorption 7, 8