In the past, whole cow’s milk was considered an adequate replacement for iron-fortified formula in infants more than six months of age who were getting at least one-third of their calories from supplemental food. Recently, this recommendation has been re-examined. Infants fed whole cow’s milk after six months of age have been found to have poorer iron status than infants who are fed iron-fortified formula. Other studies have shown substantial enteric blood loss in infants more than six months of age who are fed whole cow’s milk. Also, questions have arisen regarding the bioavailability of the iron in infant cereals, which are often used to provide supplemental iron. Based on this and other evidence, whole cow’s-milk and low-iron formulas should not be used during the first year of life. Ideally, infants should be breast-fed for the first six to 12 months of life, with iron-fortified formula being the only acceptable alternative during the first year.25,27
Vitamins
Vitamin K is effective prophylaxis against hemorrhagic diseases of the newborn because it minimizes the postnatal decline of vitamin K-dependent coagulation factors. Therefore, regardless of the method of feeding, all infants should receive 0.5 to 1.0 mg of intramuscular vitamin K or 1.0 to 2.0 mg orally in the immediate newborn period? Although breast milk contains only 5 to 10 percent of the vitamin K contained in infant formula, no adverse effects have been demonstrated with breast feeding, and vitamin K supplementation of exclusively breast-fed infants beyond the initial dose has not been recommended? Although human milk contains low levels of vitamin D, the term infant of a well-nourished mother is not likely to need vitamin D supplementation as long as the infant receives adequate exposure to sunlight. Daily supplements of vitamin D (5 to 7.5 ug) can be given to infants receiving insufficient exposure to sunlight. As an alternative, increasing maternal vitamin D intake increases the vitamin D content in breast milk and may be the best method of ensuring adequate vitamin D for the infant. Vitamin B content of human milk also depends on maternal dietary intake. As a result, vegetarian mothers are at risk for vitamin B6- and B12-deficient milk unless they supplement their diets with these vitamins. Conversely, human milk is rich in vitamins A, C and E, so no supplementation of these vitamins is needed for breast-fed infants? Because infant formulas are fortified with vitamins and minerals, formula-fed term infants do not require vitamin and mineral supplements during the first six months of life, except the initial postnatal dose of vitamin K. If formula is combined with solid food after six months of age, infants can continue without vitamin and mineral supplements?
Iron
Although human milk contains only 0.3 mg iron per L, it is approximately 50 percent absorbed. Iron from breast milk helps delay depletion of neonatal iron stores; however, breast-fed infants need iron supplementation at six months of age, usually in the form of iron fortified cereal? To ensure adequate iron for the term infant who is not receiving human milk, the AAP Committee on Nutrition has recommended that only iron-fortified formulas be used for all formula-fed infants. Despite this recommendation, approximately 20 percent of formula-fed infants receive low-iron formulas. This fact is especially alarming because low-iron formulas have been associated with iron deficiency and have not been associated with fewer adverse gastrointestinal reactions than iron-fortified formulas. Low-iron formulas simply have no role in any infant’s nutritional program?
Fluoride
Fluoride supplements for children have recently been reassessed because of an increasing incidence of dental fluorosis. Dental fluorosis is caused by excess fluoride ingestion, leading to enamel protein retention, hypomineralization of the dental enamel and destruction and disruption of crystal formation. Although teeth remain resistant to caries, fluorosis causes cosmetic dental changes ranging from barely perceptible white striations to brownish-gray stains. For infants, the main sources of fluoride include fluoridated water, toothpaste and fluoride supplements. Unfortunately, water is not uniformly fluoridated throughout the United States, and infants ingest variable, though significant, amounts of fluoride from toothpaste.
Since fluoride from both of these sources cannot be easily quantified or readily controlled, recommendations for fluoride supplements have been modified to decrease the risk of fluorosis. These new recommendations are outlined in Table 3. It is important to note that fluoride supplementation is no longer recommended for infants under six months of age.
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