Ask The Armadillo - follow on formula con linked to impaired development

Q. Hi Armadillo,
I've got a Q for you!  I'm confused (and so are a lot of mums I speak to) about this claim by follow-on milk producers that breastfed babies and those weaned onto cows milk are going to be short of iron. Can you shed any light?
Many thanks,
Jude

A. Hi Jude
Ah the giant marketing machine that is follow on milk, and it's huge iron count. Yes, how did the human race manage before it?

An interesting fact you may or may not be aware of, is that until the 1980's/90's there was no such thing as "follow on milks". They were developed partly because the market for young baby infant formula was saturated (s'always about the money), and partly to dodge the new regulations that were starting to appear which banned the promotion of young baby infant formula.

Follow on milk (for infants over 6 months) was not restricted in these regulations, because it did not exist! So manufacturers then moved to advertise their similarly packaged and branded follow on milk, because parents very often mistake these adverts for young baby formula. There have been numerous follow on adverts banned because they used infants that were too young or because they used misleading statements. In fact, when a 2005 survey asked 1,000 new mothers and pregnant women, two thirds (60%) said they had seen or heard advertising for young baby infant formula in the past year. Worryingly more than a third of women who had seen formula advertising said that the message conveyed was that infant formula is 'as good as' or 'better than' breastmilk. Clever huh?

The "very large iron scam" as I fondly like to term it, is almost as clever - but not quite...

Because obviously pre the 80's babies weren't all wandering round iron deficient.  No mammal biologically needs the milk of another species to survive and thrive, otherwise the human race would have died out long before follow on milk was around.  Even babies not having breastmilk after twelve months, don't need cow's milk or follow on formula to remain healthy.  Some babies are more at risk of deficiency, such as those born preterm, or if mum has diabetes - if you are unsure, check with your healthcare provider.

Before I go any further, it's important to understand the different types of iron we can consume.  Heme iron is found in animal foods that originally contained haemoglobin, such as red meats, fish, and poultry;  iron in plant foods such as lentils and beans is arranged in a chemical structure called non-heme iron, and it's this form of iron that is added to iron-enriched and iron-fortified foods. Heme iron is better absorbed and more bioavailable than non-heme.

Now, the recommended daily iron allowance (RDA) for a child 1-3 years is around 6 mg/day. 
So take the advert with the giant cup of milk, and wow imagine having to drink all this to give your baby the RDA -  gosh yes, mammoth!  But hang on, infants at 6 months plus aren't reliant solely on milk - at this point they are starting to consume solids and take iron in their diet too, by twelve months most are eating a good varied diet - so their intake is a combination of iron in milk + iron in food.  If their daily iron requirements are met in just a couple of beakers of "high iron formula", isn't baby very quickly at risk of being well over the daily recommended allowance if they eat much?

Nowhere in this marketing plan does anyone mention the risks of too much iron, but many source suggest that too much is just as bad as too little.

A study published November 2011 found infants who received iron fortified infant formula have poorer long-term developmental outcomes.

Betsy Lozoff, M.D explored long-term developmental outcomes after ten years for infants who were given iron-fortified formula. In a randomised controlled trial they followed up 473 children after ten years. Between 6-9 months of age 244 were in the iron-fortified group and 229 in the low-iron group

Researchers gathered data on their IQ, arithmetic skills, VMI (visual-motor integration), motor functioning, visual perception and spatial memory.

At the age of ten the researchers detected no significant differences in the iron status in the children of both groups. 4.1% (9) of the infants and 6.9% (17) of the ten-year-olds were diagnosed with iron deficiency in the iron-fortified group.

The children in the iron-fortified group scored lower in every outcome measured at ten years, with statistically significantly lower scores in spatial memory and VMI, compared to those in the non-iron group. They showed suggestive trends that did not reach statistical significance in arithmetic skills, motor coordination, visual perception and IQ.

Furthermore:

The lowest ten year follow-up scores were found among the infants with the highest hemoglobin scores who had been given iron-fortified formula. However, the highest scores were among the iron-fortified formula infants whose hemoglobin levels at six months of age were the lowest.

The authors wrote:

"In conclusion, this study indicates poorer long-term developmental outcome in infants with high hemoglobin concentrations who received formula fortified with iron at levels currently used in the United States. Optimal amounts of iron in infant formula warrant further study."

http://archpedi.ama-assn.org/cgi/content/short/archpediatrics.2011.197

So this considers US levels - I decided to investigate how things stood in the UK.

In the study fortified formula was mean 12.7 mg/L and non fortified was mean 2.3 mg/L

SMA Stage 2 Follow On Milk - 12 mg/L
Aptamil Follow On Milk - 10 mg/L
Cow & Gate Follow On Milk - 10 mg/L
Hipp Organic - 10 mg/L

Any unabsorbed iron sits providing the perfect environment for harmful pathogens to live and feed and for cancer cells to thrive.  Excess iron also creates free radicals, which have been linked with everything from heart disease to ageing.  Someone who feels very strongly about this issue and probably presents "worst case scenario" is Ray Peat - but a quick google of "iron causes free radicals" or "risks of too much iron", finds this is not a new concern to many.

Add to this the risks of aluminium from follow on tins - and it's hardly appealing....

Those who don't know very much about breastmilk will tell you how low it is in iron compared to breastmilk substitutes (which as the above study shows is likely to be a good thing!)  Something further to consider is only 7-12% of the total amount in substitutes is absorbed to be used by baby - compared to at least 50% in breastmilk. The result from larger amounts in formula is a lot of excess iron that can't be used by the body.

The iron in breastmilk (NOT related to maternal intake during lactation),  isn't just "any old iron", and it's not just wildly floating around.  It's bound with a glyco protein called lactoferrin.

Human lactoferrin carries the iron and as it is also bactericidal and antiviral to many harmful pathogens including E coli, protecting the iron by reacting with the cell membrane of bacteria it comes in contact with; it is also an effective anti fungal against Candida.  Breastmilk also contains high levels of lactose and vitamin C, further aiding absorption.  There is never any spare iron sitting round to cause problems.

As mentioned above, iron is obviously also found in foods.  Red meat is a fantastic source of heme iron for young children as it also contains the essential B vitamins and zinc- I always find it very confusing when parents use the 6 month guideline to introduce solid foods, and then use foods such as baby rice (irk!) or plain veg - which are from an introduction plan aimed at prematurely weaned infants and offer little nutritionally. 

If a baby is having plain doorstep milk from a year instead of formula (and really, why line their pockets a moment longer than you need to?)  ensuring you offer other iron rich foods instead is recommended.  Chicken livers are very high at 12.8 mg per 3 1/2 oz serving, beef tenderloin offers approx 3mg per 3oz and dark turkey approx 2mg.  Good non heme sources include soya beans at around 8.8mg per cup (although some debate this claiming some proteins found in soybeans can also inhibit absorption), followed by pumpkin seeds (4mg per 30g) lentils, beans, potatoes, broccoli, spinach, mushrooms, raisins and wholewheat bread (see all the sources of iron that creep in?) plus of course fortified cereals. 

It is important to ensure baby doesn't consume too much doorstep milk ie to the detriment of solids intake.  Cows milk is very low in iron naturally, so if baby is filling up on that and refusing foods, there is increased risk of deficiency.  In addition too much calcium is also known to inhibit iron absorption, whilst offering foods rich in vitamin C alongside iron rich foods, assist.

Hope this answers your question?
AA

UPDATE - The Advertising Standards Authority have banned the "iron count advert" as misleading.