Postpartum anaemia and Breastfeeding

Postpartum fatigue can seem like a given with a newborn. But it can be significantly amplified when the mother has anaemia. Common after childbirth, anaemia in the breastfeeding mother has real consequences for her health and her experience of breastfeeding.

Definition and prevalence of postpartum anaemia

Postpartum anaemia is defined as a haemoglobin concentration below 12 g/dL. It affects between 22 and 50% of women in high-income countries, and up to 50 to 80% in low- and middle-income countries.

Its primary cause is almost always twofold: an iron deficit already present at the time of delivery (very common by the end of pregnancy, when iron requirements increase considerably), compounded by blood loss during childbirth. Additional contributing factors (vitamin B12 or folate deficiency)can also result in what is referred to as mixed anaemia.

Postpartum anaemia: Signs and symptoms

Postpartum iron deficiency anaemia can present with the following:

• Intense, disproportionate fatigue, even after a reasonable night's sleep

• Shortness of breath with minimal exertion

• Palpitations, a racing heart

• Difficulty concentrating, a sense of "brain fog"

• Irritability, emotional instability

• Headaches

• Pallor (conjunctivae, palms of the hands)

• Increased susceptibility to infections

One important point: postpartum anaemia can be mistaken for postnatal depression, with which it shares several symptoms (fatigue, cognitive difficulties, low mood). The two conditions can also coexist, and anaemia may contribute to depression.

Consequences for the mother

A systematic review and meta-analysis published in BMC Public Health (Moya et al., 2022) demonstrates that postpartum anaemia significantly impairs maternal health-related quality of life, with documented impacts on fatigue, depression, and potentially on the mother-infant relationship.

In terms of breastfeeding, several mechanisms may be at play:

• Severe fatigue can disrupt the regularity and frequency of feeds, and thus indirectly affect milk production.

• Untreated anaemia can contribute to early weaning , not as an informed choice, but as a consequence of exhaustion

  
  

What are the consequences for the baby's iron levels?

Breast milk iron is relatively stable

Human milk naturally contains little iron, but that iron is highly bioavailable. In most situations, the iron concentration of breast milk varies little with the mother's iron status.

The impact on neonatal iron stores is primarily determined in utero

The key factor for a newborn's iron stores is not so much the iron content of breast milk as the placental transfer of iron during late pregnancy. If the mother was anaemic or iron-deficient during pregnancy, neonatal iron stores may already be compromised at birth.

Similarly, early cord clamping at delivery can affect the infant's risk of anaemia. Delayed cord clamping is now recommended(a piece of information parents should be given when offered the option of cord blood donation).

Iron is essential for the baby's development

Iron deficiency can have an impact on a child's cognitive and motor development. Poor appetite, slow weight gain, and pallor can be signs of anaemia in an infant.

This is a reason to treat maternal anaemia without delay, and to ensure paediatric monitoring of iron status in at-risk infants (premature birth, maternal anaemia during pregnancy, early cord clamping).

Prevention of iron deficiency anaemia in infants

To reduce the risk of iron deficiency, the Committee on Nutrition of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) recommends the following measures:

• Delayed cord clamping

• Use of an iron-fortified infant formula for non-breastfed infants

• Introduction of iron-rich complementary foods from six months of age

• Avoiding cow's milk as the main milk source before twelve months, then limiting intake to 500 mL/day thereafter

Treatment of maternal anaemia

Postpartum anaemia is treatable — and treatment is fully compatible with breastfeeding. Here are the available options.

1. Oral iron

• Oral iron is ideally taken away from meals for better absorption, but can be taken with food if digestive side effects are a concern.

• Tea, coffee, and dairy products reduce iron absorption: avoid consuming them at the same time as the supplement.

• Taking vitamin C (citrus fruit, raw bell pepper) alongside the supplement improves absorption.

• Digestive side effects (constipation, nausea) are common. If poorly tolerated, a different formulation or alternate-day dosing may be considered with the prescribing clinician.

• Oral iron does not pass into breast milk in significant amounts: there is no contraindication to breastfeeding.

  
  

2. Intravenous iron

Reserved for severe anaemia, situations requiring rapid correction, or cases of intolerance or failure to respond to oral treatment, intravenous iron allows for faster haematological recovery.

IV iron is also compatible with breastfeeding: it does not alter the composition of breast milk.

3. Blood transfusion

Reserved for emergency situations (very low haemoglobin with haemodynamic compromise), transfusion is considered only as a last resort.

4. Diet

Enriching the diet with iron-rich foods remains useful for prevention and as a complement to treatment, but is not sufficient to correct established anaemia on its own. Foods richest in haem iron (the most readily absorbed form) include: red meat, offal (particularly liver), and shellfish (clams, oysters). Non-haem iron from plant-based sources (legumes, spinach, sesame seeds, tofu) is less well absorbed, but remains valuable , especially when paired with vitamin C.

When to seek advice

If you are experiencing several of the symptoms described above in the weeks or months following your delivery, speak to your GP, midwife, or gynaecologist so they can assess whether blood tests are warranted.

In summary

Postpartum anaemia is common and can have real consequences: profound fatigue, increased risk of depression, indirect effects on breastfeeding, and,particularly when present during pregnancy, a potential risk to the infant's iron stores. It is treatable effectively and quickly, without any restriction on breastfeeding.

Elise Armoiry — IBCLC, founder of My Baby Moon Over 2,000 families supported since 2014.

📞 07.49.50.67.82 |

📧 info@mybabymoonibclc.com

Book an appointment

References

1. Moya E, Phiri N, Choko AT, Mwangi MN, Phiri KS. Effect of postpartum anaemia on maternal health-related quality of life: a systematic review and meta-analysis. BMC Public Health. 2022;22:371. DOI: 10.1186/s12889-022-12710-2

2. Jensen MCH, Holm C, Jørgensen KJ, Schroll JB. Treatment for women with postpartum iron deficiency anaemia. Cochrane Database Syst Rev. 2024 Dec 13;12(12):CD010861. DOI: 10.1002/14651858.CD010861.pub3. PMID: 39670550; PMCID: PMC11639052.

3. Friel J, Qasem W, Cai C. Iron and the Breastfed Infant. Antioxidants (Basel). 2018 Apr 6;7(4):54. DOI: 10.3390/antiox7040054. PMID: 29642400; PMCID: PMC5946120.

4. LactMed – Iron salts.

5. Marques RF, Taddei JA, Lopez FA, Braga JA. Breastfeeding exclusively and iron deficiency anemia during the first 6 months of age. Rev Assoc Med Bras (1992). 2014 Jan-Feb;60(1):18-22. DOI: 10.1590/1806-9282.60.01.006. PMID: 24918847.

6. Svensson L, Chmielewski G, Czyżewska E, et al. Effect of Low-Dose Iron Supplementation on Early Development in Breastfed Infants: A Randomized Clinical Trial. JAMA Pediatr. 2024;178(7):649–656. DOI: 10.1001/jamapediatrics.2024.1095

7. Wang B, Zhan S, Gong T, Lee L. Iron therapy for improving psychomotor development and cognitive function in children under the age of three with iron deficiency anaemia. Cochrane Database Syst Rev. 2013 Jun 6;2013(6):CD001444. DOI: 10.1002/14651858.CD001444.pub2. PMID: 23744449; PMCID: PMC7064814.

8. Canadian Paediatric Society, Nutrition and Gastroenterology Committee. Iron needs up to two years of age. 2019.

This article is intended to provide general information and does not replace medical advice or an individualised consultation.