When to initiate Iron Supplementation in PreTerm Infants

• There are wide variations in the dose, initiation and duration of supplementation and iron compounds used for enteral supplementation
• Iron supplementation is not recommended nor is it necessary during the transition period soon after birth 
• an exogenous source of 2–4 mg/kg d⁻¹ iron is recommended during the period of stable growth, beginning at 4–8 weeks and continuing until 12–15 months of age. Whereas these recommendations provide useful guidelines for iron therapy in preterm infants, they may not be universally applicable as discussed below

TIME of INITIATION:

• ranged from 14 days to 10 weeks among the neonatal units. The current recommendation is to begin supplementation from 4–8 wks of age, irrespective of gestational age or birth weight
• However, beginning supplementation earlier may be prudent for the more immature preterm infants, many of who may be in negative iron balance by one month of age 
• supplementing 2–5 mg/kg d⁻¹ of iron from 2 weeks of age reduces the need for erythrocyte transfusions and the risk of iron deficiency between 2 and 6 months of age
• Early iron supplementation was tolerated well and was not associated with morbidities

HARMS of EARLIER INITIATION

• On the other hand, the risk of iron-induced hemolysis in preterm infants with vitamin E deficiency is maximal during the first 6 weeks of life
• Serum iron and ferritin concentrations remain elevated during the first 4–6 wk of life even without supplementation. There is a potential for iron excess with higher doses of supplementation since enteral iron absorption appears to be poorly regulated during the first month of life in ELBW infants
• Furthermore, supplemental iron is better incorporated into red cells when it is administered after the onset of erythropoiesis. These studies would support delaying iron supplementation until 4–6 wk.

RECOMMENDATIONS:

• based on Malaysian Paeds Protocol, recommend to initiate at about 4 weeks of life at 2-3mg/kg/day.
• However, further changes can be carried out based on other needs and factors such as ferritin level, maturity, early negative iron balance etc.

References:

1. Iron Therapy for Pre Term Infants. Raghavendra et al Clin Perinatol. 2009 Mar; 36(1): 27–42.
2. Neonatal Medication Protocol (based on Neofax 2012) http://kemh.health.wa.gov.au/services/nccu/guidelines/drug_protocols/FerrousSulphate.pdf\
3. Frank Shann
4. Malaysian Paediatric Protocol (3^rd Edition)