Anemia is a common complication for lactating mothers, partly as a result of the high incidence of anemia in pregnancy. It is estimated that 33% of American women are anemic in their pregnancy.

A study was conducted at a large private urban hospital in the north central United States, exploring the relationship between anemia and insufficient milk supply with 630 first time mothers. The frequency of anemia was 22% of mothers with postpartum hemoglobin of <10g/dL. Anemic mothers reported a higher level of symptomatology associated with low milk supply and were more frequently classified as having insufficient milk syndrome.

Mothers with the syndrome reported a shorter period of full breastfeeding, and weaned at an earlier age. They identified not having enough milk, baby nursing too often, and baby not gaining enough weight as the main reasons for discontinuing breastfeeding. Anemic mothers reported that “not enough milk” was the main reason for weaning more often than nonanemic mothers in both groups.

The study results suggest that anemia is associated with the development of insufficient milk, which in turn is related to duration of full breastfeeding and to age at weaning (27). The data reported in this study suggests that anemia, an important indicator of maternal health, is associated with the development of insufficient milk. Insufficient milk, in turn, was related to duration of full breastfeeding and even more dramatically to age at weaning. In this study breastfeeding durations were shorter for anemic than for nonanemic mothers.

There is a consensus in the literature that breastfeeding women worldwide cite insufficient milk as a primary reason for early weaning and introducing human milk substitutes into their babies’ diets.

Misconception of “Probable” Insufficient Milk Supply

In contrast to the above-mentioned consensus in the literature, scientific understanding of insufficient milk reflects diversity of opinion about the nature of the phenomenon. A critical conceptual issue revolves around the veracity of maternal reporting of insufficient milk: Is there really not enough milk, or do women’s reports reflect a misperception of insufficiency?

This study indicates a belief in the reality of the syndrome since the indicators such as impressive display of hunger cues by the baby or slow infant weight gain suggest that the baby actually receives insufficient milk. Insufficient milk can be considered a continuous variable or a discrete phenomenon reflecting a syndrome. (27)

Interestingly, in the study of first time breastfeeding mothers studying the correlation of anemia and insufficient milk supply, mothers without the syndrome listed employment conflicts, infant disinterest and “time seemed right” as the primary reasons for weaning. The anemic mothers reported that “not enough milk” was the main reason for weaning more often than nonanemic mothers.

Iron Deficiency Anemia

While there are many causes for anemia, the most common reason for lactating and pregnant women is iron deficiency. Iron deficiency is the most common cause of anemia in women of childbearing age worldwide.

Anemia is the reduction in either the number of red blood cells or the amount of hemoglobin (iron containing portion) of the red blood cells. This results in a decrease in the amount of oxygen available to the cells of the body. As a result, they have less energy available to perform their normal functions. Important process such as muscular activity and cell building and repair slow down and become less efficient. Iron deficiency can lead to impaired delivery of oxygen to the tissues, to anemia, impaired immune function, decreased energy levels, and to decreased physical performance.

Anemia is the last stage of iron deficiency. Iron-dependent enzymes involved in energy production and metabolism are the first to be affected by low iron levels. Iron is an important factor in anemia because iron is used to make hemoglobin, which is the component of red blood cells that attaches to oxygen and transports it. Iron deficiency can be caused by insufficient dietary iron intake and or absorption, or by significant blood loss. Iron deficiency is more likely to occur at certain times in life such as infancy, adolescence, pregnancy, and breastfeeding.

Pregnant (and consequently lactating) women are amongst the highest groups at risk for iron deficiency. Women become anemic due to the excessive blood losses of menstruation and delivery, increased iron requirements, diminished intake, diminished iron absorption or utilization, or a combination of these factors. Iron deficiency occurs in over 33-58% of young, healthy pregnant women.

A mild decrease in hemoglobin is a normal physiologic response to the increases in intravascular volume and demand for erythropoiesis during pregnancy. Anemia occurs with such frequency during pregnancy that it is referred to as “the most common medical complication of pregnancy.” (28)

Iron Deficiency Anemia and the Breastfeeding Woman

The iron-dependent enzymes involved in energy production and metabolism will be impaired long before anemia occurs. Impaired energy production, lowered energy levels and decreased physical performance may contribute to post-partum depression. Iron deficiency anemia lowers maternal immune response which predisposes the breastfeeding mother to clogged milk ducts, mastitis, thrush, prolonged tissue repair for sore nipple management as well as adversely affecting milk quality and breast milk volume.

Anemia is not a disease but actually is a condition that results in a group of symptoms such as weakness, fatigue, vertigo, dizziness, pallor, headache, ringing in the ears, headache, an inability to catch ones breath after physical exertion, and a racing or irregular heart beat. Some women are asymptomatic, but many become tired easily. Anemic mothers are increasingly susceptible to infection, postpartum hemorrhage, and have poor tolerance for even minimal blood loss during birth. (29) For the breastfeeding woman, anemia presents itself as a contributing factor for low milk supply, plugged ducts and mastitis, and delayed healing of sore nipples.

Under physiologic conditions, only a small amount of iron is lost from the body each day. The source of these iron losses are: the shedding of epithelial cells from the skin, gastrointestinal tract and the urinary tract; and the excretion of small amounts of iron in the sweat, urine, and bile. Women lose approximately 0.8 mg or iron per day from these sources. (4)

Women at the reproductive stage of life are at a higher risk for low iron levels through monthly blood losses. The low level carries over into pregnancy and lactation.

Another group at high risk are women who over-use anti-inflammatories such as aspirin or ibuprofen, as these can cause blood loss through irritation of the digestive tract.

The adolescent lactating mother who eats a “junk food” diet is at an especially high risk for iron deficiency.

The daily losses of iron from the body must be replaced by dietary intake of iron.(4) To maintain an adequate iron store, menstruating women need about 1.2-2 mg a day.(5) Lactating women have much greater iron requirements. They need to restore their iron losses from pregnancy and delivery, as well as meet the demands of infant requirement for iron through breast milk. Pregnant women require 5-6 mg of iron per day in the second and third trimester.

It is important that a physician for the treatment of anemia perform a thorough clinical evaluation. It is imperative that a comprehensive laboratory analysis of the blood be performed. It is critical that the underlying cause for the anemia be uncovered for appropriate therapy to be instituted.

Absorption of Iron from the Diet

The amount of iron absorbed from the diet depends on the form of iron in the food and the presence of other foods and substances in the diet. Dietary iron is present in two forms: heme and nonheme iron. Heme iron is more readily absorbed than nonheme iron (5,6) and its absorption is not affected by dietary factors. The amount of iron absorbed from heme iron is 5-10 times greater than the amount of iron absorbed from non-heme iron. (7) Heme iron is present in meat, poultry and fish. (8)

The absorption of nonheme iron is much more variable than the absorption of heme iron found in meats, and depends on dietary factors. Nonheme iron is found in grains, cereals, eggs, and dairy products. (5,9) Absorption of nonheme is influenced by the presence of other substances in the food.

Substances that inhibit the absorption on noneheme iron include:

• Tannins in tea and some vegetables (10,11)
• Calcium and phosphorus in milk (12)
• Casein and whey protein in bovine dairy products (13)
• Polyphenols in some vegetables and legumes, and coffee
• Phosphoprotein in eggs
• Phytates in grains, eggs and some vegetables and lentils
• Presence of other minerals such as calcium, zinc, and cadmium
• Soy products
• Wheat and maize flour
• EDTA, a food preservative (beer, soda, soft drinks, candy bars
• Foods containing oxalic acid. Oxalic acid interferes with iron absorption. Eat foods containing oxalic acids in moderation or omit them from the diet. Foods high in oxalic acid include almonds, cashews, chocolate, cocoa, kale, rhubarb, soda, sorrel, spinach, Swiss chard, and most nuts and beans.
• Avoid using wheat bran as a source of fiber when eating nonheme iron. Iron is removed through the stool, so it is best to not eat foods high in iron take or iron supplements with bran since it will be removed through the stools.
• Antacids and overuse of calcium supplements also decrease iron absorption.
• All of these dietary factors can interfere with iron absorption, so that even if a diet is high in iron content, the actual bioavailablility of the iron can be quite low. If a lactating woman is suffering from symptoms associated with iron deficiency anemia, it is advisable for her to avoid these foods for approximately 6 weeks as she rebuilds her iron stores through iron supplementation and dietary practices.(2) The absorption of nonheme iron can be increased by the presence of meat, poultry, fish, and vitamin C in the diet. (14,15,16)

Risk factors for Iron Deficiency

Risk factors for iron-deficiency anemia include these factors:

1. Low dietary intake of iron
2. Low dietary intake of ascorbic acid (Vitamin C)
3. Low dietary intake of meat
4. Blood loss per month or use of more than 12 sanitary pads or tampons per menstrual cycle.
5. Chronic use of aspirin
6. Low socio-economic status: African-American, Hispanic, Native American,
7. Adolescence
8. High parity and multiple gestation (17, 18,12)

Assessment of Anemic Breastfeeding Mother

A thorough assessment of possible anemia is an important breastfeeding history tool for all lactation consultants to incorporate.. Many of the breastfeeding problems that bring a lactating woman to the lactation consultant’s office or her physician’s office are related to iron-deficiency anemia -- sore nipples, exhaustion, plugged ducts, low milk supply, thrush, all these breastfeeding challenges can occur if a lactating mother is experiencing anemia.

A thorough health history and a complete physical examination are an essential component of the evaluation of the anemic woman. The purpose of the history and physical exam is to: 1) Determine whether there are signs and symptoms of anemia, 2) determine if the anemia is affecting the woman’s current health status, 3) refer the woman to her health care provider to determine whether signs and symptoms of possible medical disorders may be causing the anemia, and 4) to determine if there are familial, environmental dietary or medical disorders that may be the cause of the anemia.

Suggested questions to include in the breastfeeding history intake questionnaire to determine iron-deficiency anemia and its cause should include:

• Determine average daily iron intake
• Determine are there dietary practices that may decrease iron absorption
• Is excessive blood loss a possible cause of iron deficiency?
• Gastrointestinal disorders causing blood loss? Intestinal parasites?

It is best to have a complete blood test to determine if you have an iron deficiency before taking iron supplements. Excess iron can damage the liver, heart, pancreas and immune cell activity, and has been linked to cancer. Iron supplements are to be used only under the supervision of a qualified health care provider.

Inorganic iron supplements are coming under sever attack as the potential cause of many health problems. Nutritional research journals are showing interesting facts and studies about the side effects of iron tablets. Not only can excess iron accumulate in the body to toxic levels, it may also interfere with immunity and promote cancer. Iron is an important mineral for pregnancy and lactation, the question is only how much iron and in what form.

Dosage

Treatment for iron-deficiency anemia should begin with 60-120mg of elemental iron daily during pregnancy. The supplements should be started gradually, because tolerance to side effects is improved when iron is initiated at a lower dose. The dose should be increased gradually over several days until the full therapeutic dose is achieved. (19)

Many clinicians recommend higher dosages of elemental iron but these higher dosages can be problematic with gastrointestinal side effects. The use of high dosages of iron can also decrease the absorption of other important nutrients, such as zinc. (20)

Iron Preparations

There are many types of iron preparations available. When selecting an iron preparation it is good to remember these things:

• The amount of elemental iron present in the supplement
• The form of the iron (ferrous or ferric) in the supplement
• Whether other supplements (vitamins and minerals) are present
• Whether the preparation is enteric coated or in a delayed-release form

Form of iron

Iron comes in two forms: ferrous or ferric salts. Absorption of iron form the ferrous form is three times greater than the absorption of the ferric. There are several types of ferrous salts available: sulfate, gluconate, fumerate, and succinate. The absorption of each of these salts is roughly equivalent. A recent survey determined that the cost of these varying products were approximately the same.

Handy tips to remember for selection and dosing of iron supplements

• Iron is best absorbed when given in a tablet that contains only iron salt. Anemia should not be treated with prenatal vitamin/mineral supplement because the absorption of iron from these supplements is variable and less efficient than the absorption of iron from simple iron preparations.
• It is best not to take iron supplements that are enteric coated. The enteric-coated preparations are less effective because exposure to gastric juices plays an important role in iron absorption.
• It is best not to take a time-released iron supplement since the majority of iron absorption occurs in the upper part of the small intestine. The effectiveness of these delayed release forms varies widely. And they are expensive.
• For the most efficient absorption of iron, it should be taken in a naturally biochelated form, the form that nature supplies.
• It’s best to take the iron supplement on an empty stomach so food components will not interfere with the absorption (as mentioned earlier). When iron supplements are taken with meals, absorption is decreased by 40-50% (19)
• Don’t take iron supplement with coffee, tea or soft drinks since these beverages interfere with iron absorption.
• If iron assimilation is poor, and iron defiency results, it is best to use a good herbal liver tonic to stimulate digestion and absorption. The Iron-Plus-Calcium Tincture below is one suggestion.
• Natural iron supplements such as Iron-Plus-Calcium Tincture or spirulina. Floridax Herbs with Iron or Nature Works Herbal Iron, liquid iron supplements made from wildcrafted and organic herbs are available in natural food stores.
• Women who have trouble swallowing tablets and capsules can be given liquid iron supplements. Since liquid iron supplements can cause staining of teeth, to prevent staining of the teeth these preparations should be diluted in a full glass of water and sipped with a straw.. Avoid swishing before swallowing.
• Caution mothers to keep iron supplements out of reach of children. In 1991 there were 5,144 cases of pediatric iron poisoning in the US. Iron poisoning can be fatal and there are reports of toddler deaths caused by consumption of prenatal iron supplements. (21)
• The two best times to take iron supplementation is upon waking up after the night fast and before bedtime. Iron is better tolerated if it is taken at bedtime. (12)
• And last but not least, cooking foods in the good old-fashioned iron skillet provides maternal blood with an extra boost of iron.

Iron-Plus-Calcium Tincture

Also a Tincture for the Liver and Digestion

3 parts nettle
2 parts yellow dock root
1 part watercress
2 parts spirulina
1 part kelp
1 part lamb’s quarter

Easing Side Effects of Supplemental Iron

Side effects of oral iron therapy include heartburn, diarrhea, bloating, abdominal cramping, nausea and gastrointestinal upset. About 12% of patients experience side effects from oral iron therapy. (19) These tips will help offset these discomforts:

• Take iron supplement at bedtime, it is better tolerated at bedtime.
• Reduce the dose of elemental iron since the side effects are related to the dose.
• Switch to a supplement with a lower concentration of elemental iron in the supplement such as ferrous gluconate or ferrous lactate. (22)

Maintenance of Iron Replacement Therapy

Even though most iron deficiency anemias are usually resolved in six to eight weeks (23), iron therapy should be continued after the hemoglobin returns to normal to replenish iron stores. After the resolution of the anemia, iron is usually supplemented for three to six months. (19, 24) Another option is to have the mother’s primary physician monitor serum ferritin levels monthly and continue treatment until the serum ferritin is greater than 50µg/ L. (24)

Nutritional Support

Increasing iron levels in the food a breastfeeding mother eats may help partially or completely overcome poor iron absorption.

Iron is readily available in dark, leafy vegetables and in dark-red vegetables such as red chard, beets and red cabbage. It is found abundantly in black strap molasses, apples, dried apricots, asparagus, bananas, broccoli, egg yolks, organ meats, lean meat, shell fish, kelp, leafy greens, okra, parsley, peas, plums, prunes, purple grapes, raisins, rice bran, squash, turnip greens, whole grains, and yams. It is good to eat foods high in Vitamin C to enhance iron absorption. Vitamin C supplementation has been shown to greatly enhance the absorption of dietary iron. (1) Vitamin C alone will often increase body iron stores. 500mg of vitamin C with every meal will assist with the absorption of dietary iron.

Calf liver: Probably one of the best sources of natural iron available, it is rich not only in iron but also in the B-vitamins that stimulate red blood cell production, in addition to other vitamins and minerals. 4 to 6 oz of calf liver per day is recommended. Liquefied liver extracts are an even better source of highly bioavailable nutrients than regular liver. These extracts have the benefits of liver but are free of fats, cholesterol, and fat-soluble vitamins. The recommended dosage for a high-quality aqueous (hydrolyzed) liver extract would be 4 to 6 mg of heme iron content.

Green Leafy Vegetables: Green leafy vegetables are a benefit for any type of anemia. These vegetables contain natural fat-soluble chlorophyll as well as other important nutrients, including iron and folic acid. The chlorophyll is similar to the hemoglobin.

Black Strap Molasses: 1 Tablespoon of Black Strap Molasses twice daily is highly recommended because it is a good source of iron and B vitamins.

In addition to black strap molasses,

Brewer’s yeast is another good food supplement. Use as directed on the label. Brewer’s yeast is rich in basic nutrients, is an excellent source of protein and a good source of B vitamins, amino acids and minerals. It is one of the best immune-enhancing supplements available in food form. It helps speed wound healing through an increase in the production of collagen. It has anti-oxidant properties to allow the tissues to take in more oxygen for healing. (3)

Brewer’s Yeast also contains naturally occurring nucleic acids (DNA and RNA), that are said to enhance the activity of the immune system. Brewers yeast is not toxic and can be taken daily without any side effects. Brewer’s yeast comes in tablets and powder form. It can be sprinkled on food or drink.

Other tips to remember that enhances iron absorption include:

• Eat low-mercury fish at the same time as vegetables containing iron (this increases iron absorption)
• Omitting all sugar from the diet increases iron absorption as well.
• Avoid drinking black tea, coffee or soda at mealtimes as this interferes with iron absorption.

Recommended Vitamin and Mineral Supplementation

The following supplements can be used by breastfeeding mothers to treat iron deficiency:

Use Ferrous Gluconate, Iron Succinate or Iron fumarate twice per day between meals. If this results in abdominal discomfort, take 30 mg with meals three times per day.

Or: Floridax Iron, or +Herbs from Salus Haus contains a readily absorbable form of iron that is nontoxic and a natural source.

Vitamin C: 3,000 to 10,000 mg daily (1,000mg 3X a day with meals) Use it with iron supplement to enhance absorption.

Folic Acid: 800 mcg to 1,200mg daily. Is needed for red blood cell formation.

Vitamin B12: 2,000mcg 3 times daily. Vegetarians should take extra B12 daily. It is essential for red blood cell production. It breaks down and prepares protein for cellular use.

Vitamin B complex: Take 50 mg 3 times daily

Vitamin B5 100mg daily. It is important in red blood cell production.

Vitamin B6 (pyridoxine) Take100 mg daily. It is involved with cellular reproduction.

The following herbs are all good for anemia: Alfalfa, bilberry, cherry, dandelion, grape skins, hawthorn berry, mullein, nettle, Oregon grape root, red raspberry, shepherd’s purse, watercress

Nettle tea is rich in iron; drink it daily.

Beet and carrot juice are excellent to help treat anemia.

Homeopathic Remedies

Ferr.phos. (Ferrum phosphoricum, iron phosphate) helps assimilation of iron from food.

Nat.mur.(Natrum muriaticum) Take for anemia with constipation, headache and a tendency to cold sores.

Balch, Balch, Prescription for Nutritional Healing, 1997

Murray, Pizzorno, Encylopedia of Natural Medicine, 1998

Norman Shealy MD, Ph.D., The Illustrated Encyclopedia of Natural Remedies

1. Fairbanks , Beutler, ”Iron” in M.E. Shils and V.R. Young eds., Modern Nutrition in Health and Disease, 7th ed. (Philadelphia, PA: Lea and Febiger, 1998), 193-226.

2. J.E. Morley, ‘Nutritional Status of the Elderly,’ Am, J Med 81 (1996): 679-95.

3. L. Page, ND, Ph.D, Healthy Healing; 1997, pg.189

4. Bothwell, Baynes, MacFarlane, MacPhail, Nutritional iron requirements and food iron absorption. J Intern Med 1989; 226:357-65

5. Hallberg L, Bioavailabilty of dietary iron in man. Ann Rev Nutr 1981:1:123-47

6. Finch, Huebers, Perspectives in iron metabolism. N Engl J Med 1982; 306: 1520-8.

7. Cook, Adaptation in iron metabolism. Am J Clin Nutr 1990;51:301-8

8. Bothwell, Charlton, Iron deficiency in women. New York: International Anemia Consultative Group, Nutrition Foundation, 1981

9. Kelton, Cruickshank, Hematologic disorders of pregnancy. In Burron GN, Ferris TF, editors. Medical complications during pregnancy. 3rd ed. Philadephia; B Saunders, 1988

10. Lee, Nutritional factors of erythrocytes. In Lee GR, Bithell TC, Foerster J, Athens JW, Lukens JN editors. Wintrobe’s clinical hematology. 9th ed (vol 1) Philadelphia: Lea & Febiger, 1993.

11. Disler, Lynch, Charlton, Torrance, Bothwell, Walker, Mayet. The effect of tea on iron absorption. Gut 1975; 16: 193-200.

12. Institute of Medicine, Nutrition during pregnancy. Washington DC; National Academy Press, 1990.

13. Hurrell, Lynch, Trinidad, Dassenko, Cook, Iron absorption in humans as influlenced by bovine milk proteins. AM J Clin. Nut 1989;49:546-52.

14. Morris, An oveview of current information on bioavailabililty of dietary iron to humans. Fed Proc 1983; 42: 1716-20

15. Slatkatvitz, Clydesdale, Solubility of inorganic iron as affected by proteolytic digestion. AM J Clin Nutr 1988; 47: 487-95

16. Hunt, Mullen, Lykken, Gallagher, Nielsen, Ascorbic acid: effect on ongoing iron absorption and status in iron-depleted young women. Am J Clin Nutr 1990; 51:649-55.

17. Kim, Hungerford, Yip, Kuester, Zyrkowski, Trowbridget, Pregnancy nutrition surveillance system_United States, 1979-1990. MMWR 1992;41(SS-7):25-41

18. Cook, Adaptation in iron metabolism, Am J Cli Nutr 1990,51: 301-8

19. Lee GR, Iron Deficiency and iron-deficiency anemia. In: Lee GR, Bithell, Foerster, Athens, Lukens, editors. Wintrobe’s clinical hematology, 9th ed (vol 1). Philadelphia: Lea & Febiger. 1993 ,

20. Hambridge, Krebs, Sibley, English, Acute effects of iron therapy on zinc status during pregnancy. Obstet Gynecol, 1987; 70:593-6.

21. Centers for Disease Control and Prevention. Toddlers deaths resulting from ingestion of iron supplements~Los Angeles. 1992-1993. MMWR 1993; 42 (6):111-3

22. Bridges, Bunn, Anemias with disturbed iron metabolism. In: Wilson JD, Braunwald, Isselbacher, Petersdorf, Martin, Fauci, Root, editors. Harrison’s priniciples of internal medicine. 12th ed. New York: McGraw-Hill, 1991.

23. Perry, Morrison, Hematologic disorders in pregnancy. Obstet Gynecol Clin North Am 1992: 19: 783-99.

24. Hoffbrand, Pettit, Essential haematology. 3rd ed. Oxford:Blackwell Scientific, 1993

25. Baker, Combleet, Erythrocyte disorders In: Howanitz, Howanitz, editors. Laboratory medicine: test selection and interpretation. New York: Churchill Livingstone, 1991.

26. Janet Engstrom, Claudia Sittler, Nurse-Midwivery Management of Iron-Deficiency Anemia During Pregnancy, Journal of Nurse-Midwivery,Vol,39, No.2, 1994

27. Henly, Anderson, Avery, Hills-Bonczyk, Potter, Duckett, Anemia and Insufficient Milk in First-Time Mothers, BIRTH, 22:2, June 1995.

28. Bobak, Jensen MD, Maternity and Gynecological Care. St. Louis; Mosby, 1993

29. Murphy, O’Riordan, Newcome, et. al. Relation of haemoglobin levels in first and second trimesters to outcome of pregnancy. Lancet, 1986; 2: 992-994.