Breastfed and formula-fed infants should receive intramuscular vitamin K soon after birth to prevent classic hemorrhagic disease of the newborn (strength of recommendation [SOR]: A, systematic review of controlled trials). Routine iron supplementation for all term, healthy, breastfed infants is not proven to be safe or necessary. Formula-fed infants should be consuming formula that contains 10 to 12 mg/L of iron (SOR: A,
 2 small randomized controlled trials)

Eglash, Anne

Kendall, Susan K.

University of Missouri: MOspace

VOL 54, NO 12 / DECEMBER 2005 1089w w w. j f p o n l i n e . c o mCLINICAL INQUIRIESE V I D E N C E - B A S E D A N S W E RWhat vitamins and minerals should begiven to breastfed and bottle-fed infants?■ Evidence summaryVitamin K. The Cochrane Database ofSystematic Reviews looked at randomizedtrials to determine the effectiveness of vita-min K prophylaxis in preventing classichemorrhagic disease of the newborn.1 Twotrials demonstrated that a single dose ofintramuscular vitamin K reduced clinicalbleeding at 1 to 7 days. Oral vitamin K hasbeen studied for its effects on biochemicalindices of coagulation status, but not forits clinical effects on bleeding. A single oralvitamin K dose at birth resulted in lowervitamin K levels at 2 weeks and 1 month,compared with a single dose of intra-muscular vitamin K at birth.Iron. The iron status of exclusivelybreastfed infants vs formula-fed infantswas evaluated in a nonrandomized cohortstudy.2 Twenty-five healthy, breastfedinfants and 15 healthy infants fed high-iron formula were followed for 9 months.No differences in mean hemoglobin values were seen at any age between the 2 groups. A randomized controlled trial investi-gated the efficacy of daily and weekly ironsupplementation on iron status in 67Breastfed and formula-fed infants should receiveintramuscular vitamin K soon after birth to preventclassic hemorrhagic disease of the newborn(strength of recommendation [SOR]: A, systematicreview of controlled trials).Routine iron supplementation for all term,healthy, breastfed infants is not proven to be safe ornecessary. Formula-fed infants should be consumingformula that contains 10 to 12 mg/L of iron (SOR: A,2 small randomized controlled trials).Healthy, term infants at the highest risk forvitamin D deficiency are those who are breastfeed-ing and have dark skin or little sun exposure (SOR:B, 2 case series). Infants consuming at least 500mL of fortified formula each day do not needadditional supplementation. A recommendationof vitamin D supplementation of 200 IU/dayshould be explained to all families, particularlythose at highest risk for nutritional rickets (SOR:C, expert opinion). Infants older than 6 monthsshould receive an oral fluoride supplement of0.25 mg if they consume fluids with a water fluoride level less than 0.3 ppm (SOR: B, poor-quality randomized controlled trials).Anne Eglash, MDDepartment of Family Medicine, University of Wisconsin Medical School, MadisonSusan K. Kendall, PhD, MSLISMichigan State University, East Lansing C L I N I C A L C O M M E N T A R YEncourage breastfeeding; keep vitamin D and iron needs in mindPhysicians can help mothers give the best nutritionto their children by encouraging breastfeeding. In most cases, no supplements are required. Fromthis information, I will keep in mind the shorterhours of daylight in the winter and the skin tone of the child, as this may warrant discussion of vitamin D supplementation in infants who areexclusively breastfed. Knowing the recommenda-tions for iron supplementation will help physicianswhen counseling parents regarding formula choices.  Lastly, vitamin K has become part of theroutine protocol at delivery and should not be afactor for any child. Julia Fashner, MDPiqua, OhioJFP_1205_CI.Final  11/16/05  2:38 PM  Page 1089Routine iron supplementationfor term, healthy,breastfed infantsis not safe or necessary1090 VOL 54, NO 12 / DECEMBER 2005  THE JOURNAL OF FAMILY PRACTICECLINICAL INQUIRIESFAST TRACKexclusively breastfed infants.3 At age 4months the infants were randomized into3 groups: daily iron, weekly iron, and noiron. No significant differences weredetected in the mean weight, height, andhead circumference among the groups.The mean values of hemoglobin, meancorpuscular volume, serum iron, andtransferrin saturation were similar amongall the groups at ages 5, 6, and 7 months. A randomized, double-blind, placebo-controlled iron supplementation trialinvolved 214 exclusively breastfed infantsfrom 4 to 9 months of age in Sweden andHonduras.4 Iron supplementation did notaffect weight gain in the groups, but lengthgain from ages 4 to 9 months was less inthe iron-supplemented groups than in theplacebo group (P<.05 for placebo vs Fe).This effect was greater in Sweden, andonly existed in Honduras for infants aged4 to 6 months with initial mean Hgb of atleast 11 mg/dL. The researchers concludethat iron supplementation may pose risksin iron-replete infants.Vitamin D. A case review of nutrition-al rickets in North Carolina between 1990and 1999 found that all 30 patients identi-fied were breastfed African Americaninfants.5 Among the 166 published cases ofrickets in the US from 1986 to 2003, 83%were categorized as African American orblack. Ninety-six percent of cases werebreastfed.6Fluoride. No infant under 6 months ofage should receive fluoride supplementa-tion to prevent dental caries because of therisk of enamel fluorosis.7 A systematicreview that evaluated fluoride for prevent-ing dental caries in primary teeth in chil-dren aged <5 years found 6 small clinicaltrials. Although the studies were not ofhigh quality, they consistently showed thatthe incidence of caries was reduced by32% to 72%.8Recommendations from othersThe American Academy of Pediatrics(AAP) recommends that:• All newborns receive vitamin K as anintramuscular dose of 0.5 to 1 mg9• All full-term appropriate-for-gestation-al-age breastfed infants receive a supplemental source of iron starting at4 to 6 months of age, preferably fromiron-enriched complementary foods.Infants should only receive formulafortified with 10 to 12 mg/L for wean-ing or supplementing breastmilk10• All infants, including those exclusivelybreastfed, should have a minimumintake of 200 IU of vitamin D per daystarting in the first 2 months of life.The National Academy of Sciencesrecommends 200 IU of vitamin D daily forall normal infants, children, and adoles-cents.11The US Preventative Services TaskForce (USPSTF) states evidence is insuffi-cient to recommend for or against the rou-tine use of iron supplements for healthyinfants.12The USPSTF, AAP, and the AmericanAcademy of Pediatric Dentistry recom-mends 0.25 mg/d of fluoride supplementfor children ages 6 months to 3 years if thefluoride concentration in the communitydrinking water is less than 0.3 ppm. Olderchildren may benefit from supplements ifthe fluoride concentration is between 0.3and 0.6 ppm.13R E F E R E N C E S1. Puckett RM, Offringa M. Prophylactic vitamin K forvitamin K deficiency bleeding in neonates. CochraneDatabase Syst Rev 2000; (4):CD002776. 2. Calvo EB, Galindo AC, Aspres NB. Iron status in exclu-sively breast-fed infants. Pediatrics 1992; 90:375–379.3. Yurdakok K, Temiz F, Yalcin SS, Gumruk F. Efficacy ofdaily and weekly iron supplementation on iron statusin exclusively breast-fed infants. J Pediatr HematolOncol 2004; 26:284–288.4. Dewey KG, Domellof M, Cohen RJ, Landa Rivera L,Hernell O, Lonnerdal B. Iron supplementation affectsgrowth and morbidity of breast-fed infants: results of arandomized trial in Sweden and Honduras. J Nutr2002; 132:3249–3255.5. Kreiter SR, Schwartz RP, Kirkman HN Jr, Charlton PA,Calikoglu AS, Davenport ML. Nutritional rickets inAfrican American breast-fed infants. J Pediatr 2000;137:153–157.6. Weisberg P, Scanlon KS, Li R, Cogswell ME. Nutritionalrickets among children in the United States: review ofcases reported between 1986 and 2003. J Clin Nutr2004; 80:1697S–1705S.7. Centers for Disease Control and Prevention.Recommendations for using fluoride to prevent andJFP_1205_CI.Final  11/16/05  2:38 PM  Page 1090control dental caries in the United States. MMWRRecomm Rep 2001; 50:1–59.8. Bader JD, Rozier G, Harris R, Lohr KN. Dental CariesPrevention: The Physician’s Role in Child Oral Health.Systematic Evidence Review no. 29. Rockville, Md:Agency for Healthcare Research and Quality, 2004.Available at: www.ahrq.gov/downloads/pub/prevent/pdfser/dentser.pdf. Accessed on November 15, 2005.9. American Academy of Pediatrics Committee on Fetusand Newborn. Controversies concerning vitamin Kand the newborn. Pediatrics 2003; 112:191–192.10. Gartner LM, Greer FR, Section on Breastfeeding andCommittee on Nutrition, American Academy ofPediatrics. Prevention of rickets and vitamin D defi-ciency: new guidelines for vitamin D intake. Pediatrics2003; 111:908–910.11. Institute of Medicine, Food and Nutrition Board,Standing Committee on the Scientific Evaluation ofDietary Reference Intakes. Vitamin D. In: DietaryReference Intakes: For Calcium, Phosphorus,Magnesium, Vitamin D, and Fluoride. Washington, DC:National Academy Press; 1997:250–287.12. DiGuiseppi C. Screening for iron deficiency anemia-including iron prophylaxis. In: US Preventive ServicesTask Force. Guide to Clinical Preventive Services. 2nded. Washington, DC: US Department of Health andHuman Services, Agency for Healthcare Research andQuality; 1996:231–246. Available at: www.ahrq.gov/clinic/2ndcps/anemia.pdf. Accessed on November 15,2005.13. American Academy of Pediatric Dentistry. Specialissue: reference manual 1994-95. Pediatric Dent 1995;16:1–96.VOL 54, NO 12 / DECEMBER 2005 1091w w w. j f p o n l i n e . c o mVitamins and minerals for infants ▲Clinical Professor of Obstetrics and Gynecology George Washington University School of MedicineUniversity of Wisconsin Medical School,Office of Continuing Education is accreditedby the ACCME to provide continuing medicaleducation for physiciansSupported by an unrestricted educational grant from Berlex Inc.■ CASE 1Estrogen deficiency during menopause: Its role in the metabolic syndromeSteven R. Goldstein, MDProfessor, Obstetrics and GynecologyNew York University School of MedicineAvailable NowApplying the data from clinical trials to your practiceLook for the CME supplement atwww.obgmanagement.comCASE STUDIES IN MENOPAUSEJames Simon, MD,Series Editor■ CASE 2Estrogen deficiency during menopause:Low bone density in asymptomatic women without osteoporosisMichael McClung, MDDirector, Oregon Osteoporosis CenterCME CREDITSJFP_1205_CI.FinalREV  11/21/05  11:53 AM  Page 1091

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