Iron Requirements for Infants with Cow Milk Protein Allergy

      Historically, cow milk has been used as a major source of protein and balanced nutrition for infants and children in resource-rich and resource-constrained countries. It is a rich source of energy, protein, and calcium. It is also an important source of fat; many of its fatty acids are readily metabolized to essential omega-3 fatty acids. Regular consumption of milk during childhood has been shown to enhance bone density later in life.
      • Goulding A.
      • Rockell J.E.
      • Black R.E.
      • Grant A.M.
      • Jones I.E.
      • Williams S.M.
      Children who avoid drinking cow's milk are at increased risk for prepubertal bone fractures.
      • Rockell J.E.
      • Williams S.M.
      • Taylor R.W.
      • Grant A.M.
      • Jones I.E.
      • Goulding A.
      Two-year changes in bone and body composition in young children with a history of prolonged milk avoidance.
      However, reliance upon whole pasteurized cow milk as the sole or major source of nutrition for infants during the first year of life can increase the risk for iron deficiency and, in extreme cases, iron-deficient anemia (IDA) for a number of reasons.
      • Domellöf M.
      • Braegger C.
      • Campoy C.
      • Colomb V.
      • Decsi T.
      • Fewtrell M.
      • et al.
      Iron requirements of infants and toddlers.
      • Thorsdottir I.
      • Thorisdottir A.V.
      Whole cow's milk in early life.
      In 1972, Woodruff et al
      • Woodruff C.W.
      • Clark J.L.
      The role of fresh cow's milk in iron deficiency. I. Albumin turnover in infants with iron deficiency anemia.
      showed that 7 of 12 infants (ages 7-17 months) with IDA who ingested between 720 and 1920 mL whole milk daily had higher albumin turnover rates than a group of 5 normal infants. Parenteral iron had no effect on albumin turnover, but replacing whole milk with reconstituted evaporated milk or soy formula decreased the high albumin turnover rates to normal levels, suggesting that large amounts of cow milk protein could result in iron and protein loss in the gastrointestinal tract. Cow milk contains low levels of ascorbic acid, a factor that increases iron absorption,
      • Gillooly M.
      • Torrance J.D.
      • Bothwell T.H.
      • MacPhail A.P.
      • Derman D.
      • Mills W.
      • et al.
      The relative effect of ascorbic acid on iron absorption from soy-based and milk-based infant formulas.
      and certain proteins that negatively impact iron absorption.
      • Hurrell R.F.
      • Lynch S.R.
      • Trinidad T.P.
      • Dassenko S.A.
      • Cook J.D.
      Iron absorption in humans as influenced by bovine milk proteins.
      Cow milk contains about 4 times more calcium than human milk, and calcium negatively impacts iron absorption.
      • Hallberg L.
      • Rossander-Hulten L.
      • Brune M.
      • Gleerup A.
      Bioavailability in man of iron in human milk and cow's milk in relation to their calcium contents.
      Furthermore, cow milk has a higher protein concentration than human milk, and ingestion of large amounts can lead to metabolic and fluid imbalances, particularly in children with febrile illnesses. Thus, several entities have recommended against whole cow milk ingestion until 9-12 months and then, only when given in moderate amounts in conjunction with appropriate complementary foods.
      • Domellöf M.
      • Braegger C.
      • Campoy C.
      • Colomb V.
      • Decsi T.
      • Fewtrell M.
      • et al.
      Iron requirements of infants and toddlers.
      • Baker R.D.
      • Greer F.R.
      American Academy of Pediatrics Committee on Nutrition
      Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0-3 years of age).
      • Thorisdottir A.V.
      • Thorsdottir I.
      • Palsson G.I.
      Nutrition and iron status of 1-year olds following a revision in infant dietary recommendations.
      • Agostoni C.
      • Decsi T.
      • Fewtrell M.
      • Goulet O.
      • Kolacek S.
      • Koletzko B.
      • et al.
      Complementary feeding: a commentary by the ESPGHAN Committee on Nutrition.
      IDA ( Iron-deficiency anemia)
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