Originally published in The Ottawa Citizen August 12, 2003
Original Title: Low iron infant formulas

Dumb and dumber.

That’s what Dr. David Mack, chief of pediatric gastroenterology at the Children’s Hospital of Eastern Ontario, thinks about low-iron infant formulas.

“On the one hand,” he says, “formula companies are adding nutrients found in breast milk to promote the development of cognitive and visual development. Yet the lack of iron has the potential to thwart this development.”

The recent addition of two essential fatty acids, decosahexanoic acid (DHA) and arachidonic acid (ARA) into some formulas is a case in point. These fatty acids promote visual acuity and cognitive development in preterm and term infants and may be involved in other critical body functions.

It is ironic, Dr. Mack says, that these same companies would offer reduced-iron formulas. In a letter to Dr. Margaret Boland, chair of the nutrition committee of the Canadian Pediatric Society, Dr. Mack shares his concerns about this trend.

Pharmacies and grocery stores provide similar shelf space for low-iron cow milk-based formulas, he observes. Parents often do not notice that the product is low in iron content. There is also the perception that both types of formula provide equal benefit.

Parents will often change formulas either on their own accord or on the advice of their health care provider if their formula-fed child becomes more fussy, has cramping, colic, acid reflux from the stomach, flatulence or increased spitting-up. But there is no evidence that links formula-iron content with these conditions.

Dr. Mack notes that one of the first tendencies is to switch in error to a low-iron formula if there is a suspicion of an intolerance to cow-milk protein.

Within his practice, he often encounters the urban myth of iron causing infant constipation. However, this is actually rare. The infrequent bowel movements of soft stools result from inadequate intake of formula.

Switching to a low-iron formula further compounds the problem. The infant suffers an increased risk of iron deficiency anemia. This anemia, or reduction of oxygen transporting red blood cells, reduces the delivery of oxygen to the developing infant, especially the brain and nervous system. Iron-deficiency anemia is associated with problems in cognitive, behavioural and physical development in infants and children.

Some parents continue with low-iron-based formulas because hospitals stock and distribute them to parents for newborn feeds.

There are a few reasons why low-iron formula use is so common. Similar product packaging, poor labelling, a general lack of knowledge regarding the importance of iron in infancy and a lack of physician and nurse intervention are some of the reasons parents continue to use these products.

But there is no scientific evidence to support this product class.

There are no known medical contraindications to using iron-fortified formulas. Professional organizations do not advocate using low-iron formulas. Even the formula company representatives discourage its use.

“Public health policy successes include the introduction of iron-fortified infant formulas in the 1970s with the prevalence of iron-deficiency anemia being dramatically reduced,” Dr. Mack notes. However, Canadian infants and children are still at risk.

So why does this product remain on the store shelves? Dr. Mack believes sales of low-iron formula must still be significant enough to continue the product line.

With the exception of cow-based formulas, all other formula groups (i.e. soy-based, hydrolysate, amino acid) are iron-fortified.

Dr. Mack has six recommendations for the use and content of cow milk-based formulas. He asks the Nutrition Committee of the Canadian Society for Pediatrics to adopt and recommend these principles.

1. Infants who are not breast-fed or partially breast-fed should receive an iron-fortified formula.

2. Discontinue the manufacture of low-iron infant formula.

3. If low-iron infant formula continues to be available to consumers, the label must contain a health warning about the risk of iron deficiency anemia and its effects upon infant growth and development.

There must be consistent labelling practices akin to other formula groups (i.e. soy, hydrolyzed and amino acid). Manufacturers should remove the term ‘with iron’ from the front label. All listings including iron content should appear on the package nutrient content label.

4. The Hospital Association recommend to their members not to supply low-iron infant formula in their hospitals.

5. The distributors of low-iron infant formula should not provide shelf-space for low- iron infant formulas. A physician note would be required to obtain low-iron infant formula.

6. The Canadian Pediatric Society and formula manufacturers continue to provide education for the public and for health care providers regarding iron and infant growth and development.

If no one buys the product, companies will not sell it. It’s one way consumers can influence health outcomes and corporate behaviour.