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Minerals, trace elements, Vit. D and bone health

Contribution of iron status at birth to infant iron status at 9 months: data from a prospective maternal-infant birth cohort in China



The contribution of iron status at birth to iron status in infancy is not known. We used a physiologic framework to evaluate how iron status at birth related to iron status at 9 months, taking iron needs and sources into account.


In a longitudinal birth cohort in China, iron status measures in cord blood and venous blood in infancy (9 months) and clinical data were prospectively collected in 545 healthy term maternal–infant dyads. We used structural equation modeling (SEM) to create a 9-month iron composite and to assess direct and indirect contributions of multiple influences on 9-month iron status. Logistic regression was used to calculate odds ratios for iron deficiency (ID), iron deficiency anemia (IDA), and anemia.


Approximately 15% (78/523) of infants were born with cord SF <75 µg/l, suggesting fetal-neonatal ID. At 9 months, 34.8% (186/535) and 19.6% (105/535) of infants had ID and IDA, respectively. The following factors were independently associated with poorer 9-month iron status: higher cord zinc protoporphyrin/heme (ZPP/H) (adjusted estimate −0.18, P < 0.001) and serum transferrin receptor (sTfR) (−0.11, P = 0.004), lower cord hemoglobin (Hb) (0.13, P = 0.004), lower birth weight (0.15, P < 0.001), male sex (0.10, P = 0.013), older age at testing (−0.26, P < 0.001), higher 9-month weight (−0.12, P = 0.006) and breastfeeding (0.38, P < 0.001). Breastfeeding at 9 months showed the strongest association, adjusting for all other factors. Compared to formula-fed infants, the odds of IDA were 19.1 (95% CI: 6.92, 52.49, P < 0.001) and 3.6 (95% CI: 1.04, 12.50, P = 0.043) times higher in breastfed and mixed-fed infants, respectively.


Indicators of iron status at birth, postnatal iron needs, and iron sources independently related to iron status at 9 months. Sex was an additional factor. Public health policies to identify and protect infants at increased risk of ID should be prioritized.

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Fig. 1: Flow chart of participants.
Fig. 2: Structural equation model of iron status at 9 months in healthy term Chinese infants.


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We acknowledge Drs. Sean Lynch and Bo Lonnerdalfor their service on the Independent Data Monitoring Committee, which had oversight of the small randomized clinical trial component. We also thank Dr. Yaping Shi and her colleagues for their assistance with participant enrollment and cord blood collection, Liqin Chen for the iron status assays, and Julie Sturza for data analysis.


This work was supported by grants from the National Institutes of Health (HD039386, B. Lozoff, Principal Investigator) and the China National Sciences Foundation (81273085, J. Shao, Principal Investigator). Iron supplements and placebo were donated by Lee’s Pharmaceutical Holdings Limited (Hong Kong). The content is solely the responsibility of the authors and does not necessarily represent the official views of the funding agencies.

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JS was a co-investigator in the Brain and Behavior in Early Iron Deficiency study and principal investigator (PI) in the grant from NSFC; BL was the overall PI of the study; BL and JS were responsible for designing and conducting the research, writing and interpreting results; NK conducted methodology and formal analysis; BR conducted data extraction and analysis; BZ was responsible for investigation and data collection. KMC contributed to writing, review and editing. All authors read and approved the final manuscript.

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Correspondence to Jie Shao.

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Shao, J., Richards, B., Kaciroti, N. et al. Contribution of iron status at birth to infant iron status at 9 months: data from a prospective maternal-infant birth cohort in China. Eur J Clin Nutr 75, 364–372 (2021).

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