European Journal of Nutrition (2021) 60:4083–4091

https://doi.org/10.1007/s00394-021-02574-4

ORIGINAL CONTRIBUTION

Does maternal iodine supplementation during the lactation have

a positive impact on neurodevelopment of children? Three‑year follow
up of a randomized controlled trial
Pantea Nazeri1 · Zhale Tahmasebinejad2 · Elizabeth N. Pearce3 · Zinat Zarezadeh1 · Tahere Tajeddini1 ·
Parvin Mirmiran2,5 · Fereidoun Azizi4

Received: 15 October 2020 / Accepted: 27 April 2021 / Published online: 11 May 2021
© Springer-Verlag GmbH Germany, part of Springer Nature 2021

Abstract
Purpose The aim of this study was to examine, for the first time, the neurodevelopmental outcomes in children whose moth-
ers received different doses of iodine supplements during lactation.
Methods We conducted a follow-up study on children whose mothers participated in a randomized clinical trial to receive
placebo, 150 µg/day or 300 µg/day of iodine until 12 months postpartum. Child neurocognitive development was assessed
at 36 months of age using the Bayley Scales of Infant and Toddler Development Third Edition. Linear mixed-model analysis
was preformed to assess iodine supplement dose effects on child cognitive, language, and motor functions.
Results A total of 122 children provided neurodevelopmental data as follows: 300 µg/d iodine group: 45; 150 µg/d iodine
group: 35; and placebo group: 42. Cognitive scores were higher in children whose mothers received 150 µg iodine/d compared
to children whose mothers received placebo [102.8 (SD 13.2) vs. 99.2 (SD 10.5); β = 4.43, P = 0.032]. However, supplemen-
tation with 150 µg iodine/d had no effect on language or motor development. No significant differences were observed in
cognitive, language, or motor functions between children whose mothers received 300 µg iodine/d and those whose mothers
received 150 µg iodine/d or placebo.
Conclusion Maternal iodine supplementation with 150 µg/d during lactation may have a beneficial effect on child cognitive
development; however, we found no evidence of either improved or delayed neurodevelopmental outcomes in children whose
mothers received iodine supplements at doses higher than recommended. Further randomized controlled trials with larger
sample sizes are needed to confirm these results.
Clinical trial registry IRCT201303164794N8; registration date: 2013-05-20

Keywords Iodine · Supplementation · Lactation · Neurocognitive development · Early childhood

3
* Parvin Mirmiran Section of Endocrinology, Diabetes and Nutrition, Boston
mirmiran@endocrine.ac.ir University School of Medicine, Boston, USA
4
* Fereidoun Azizi Endocrine Research Center, Research Institute for Endocrine
azizi@endocrine.ac.ir Sciences, Shahid Beheshti University of Medical Sciences,
P.O. Box: 19395‑4763, Tehran, Iran
1
Family Health Institute, Breastfeeding Research Center, 5
Department of Clinical Nutrition and Dietetics, Faculty
Tehran University of Medical Sciences, Tehran, Iran
of Nutrition Sciences and Food Technology, National
2
Nutrition and Endocrine Research Center, Research Institute Nutrition and Food Technology Research Institute, Shahid
for Endocrine Sciences, Shahid Beheshti University Beheshti University of Medical Sciences, P.O. Box:
of Medical Sciences, P.O. Box: 19395‑4763, Tehran, Iran 19395‑4763, Tehran, Iran

13
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Introduction
Infancy and early childhood are critical periods for brain
development due to rapid growth of brain structure and
function that occurs in the earliest years of life [1]. It has
been estimated that nearly 19 million babies born globally
every year are at risk of brain damage and reduced cog-
nitive function due to iodine deficiency [2]. Iodine is an
essential component of thyroid hormones which support
neurodevelopmental processes through neurogenesis, neu-
ronal migration, axon and dendrite growth, synaptogen-
esis, and myelination [3]; therefore, adequate iodine intake
is necessary for normal brain growth and cognitive devel-
opment [4, 5]. It is well-documented that severe iodine
deficiency in utero and in early life can result in impaired
mental function, poor school performance, and reduced
intellectual ability [6].
Although the World Health Organization does not rec-
ommend iodine supplementation for pregnant women,
lactating mothers, or infants in countries with effective
iodized salt programs [7], major medical societies such
as the American Thyroid Association [8], the Endocrine
Society [9], and the American Academy of Pediatrics [10]
recommend that pregnant women and lactating moth-
ers should take daily supplements containing 150 µg of
iodine. There is currently no definitive evidence regarding
the benefits of iodine supplementation during pregnancy
on infant/child neurocognitive development in regions
of mild-moderate iodine deficiency [11]. Some studies
not only did not report any beneficial effects but actually
reported potential negative effects on neurodevelopment of
children following maternal iodine supplementation [12,
13]. To date, few studies have investigated the potential
effects of iodine supplementation during lactation, and
existing studies have mainly focused on the iodine sta-
tus and thyroid function of lactating mothers and infants
[14–16]. No study thus far has examined the effects of
iodine supplementation on child neurocognitive develop-
ment. In addition, there is limited data available on associ-
ations between urinary or breast milk iodine concentration,
indicators of iodine status in infants, and neurodevelop-
mental outcomes [17].
We recently reported the results of a multi-center ran-
domized, double-blind, placebo-controlled trial regard-
ing the effects of different doses of iodine supplements
(i.e. placebo vs. 150 µg/d and 300 µg/d of iodine) on the
iodine status of lactating mothers and infants residing in
an area of overall iodine sufficiency [16]. The findings
indicated that although the urinary iodine concentrations
in infants of the 300 µg iodine/d group increased signifi-
cantly, the iodine status of infants in all groups studied
were ≥ 100 µg/l (a recommended population cut-off point
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European Journal of Nutrition (2021) 60:4083–4091
for iodine sufficiency during the first year of life). Supple-
mentation of lactating mothers with either 300 or 150 µg
iodine/d had no effect on infant growth parameters. These
observations raised the following questions: (1) whether
iodine supplementation during lactation is beneficial in
improving neurocognitive development in children, despite
baseline adequacy of iodine status, (2) if so, whether the
recommended dose of 150 µg iodine/d is optimal for this
purpose, and (3) whether there is a dose–response effect
for neurodevelopmental outcomes in infants whose moth-
ers received higher-dose iodine supplementation. There-
fore, in this follow-up study, for the first time, we assessed
cognitive, language, and motor development in children
whose mothers received different doses of iodine supple-
ments during lactation.
Methods
Study design and participants
This was a three-year follow-up study of infants and mothers
who participated in the randomized clinical trial of iodine
supplementation in Tehran, Iran [16].
Design of the original trial
The original trial was conducted between October 2014 and
January 2016 to investigate the effects of maternal iodine
supplementation during lactation on iodine status and
growth parameters of breastfed infants during the first year
of life. A detailed description of the design and methods of
the original trial (www.​irct.​ir; IRCT201303164794N8) has
been published elsewhere [16]. In brief, 180 lactating moth-
ers and their newborns who were referred to four health-
care centers in Tehran were randomly assigned to treatment
groups: placebo, 150 µg/d iodine, or 300 µg/d iodine, and
followed-up for 12 months. Inclusion criteria were as fol-
lows: healthy mothers with no history of thyroid disorders,
not currently using iodine-containing supplements and dis-
infectants, had a singleton birth, and intended to breastfeed
exclusively; healthy infants aged 3–5 days, born full-term
(gestational age 37–42 weeks) and at a normal birth weight
(2500–4200 g). Newborns with thyroid stimulating hormone
concentration outside of the reference range (> 5 mIU/l in
heel-prick blood samples) were excluded and referred for
treatment. In lactating mothers and infants, urinary and
breast milk iodine concentrations and anthropometric meas-
urements were assessed as the primary outcomes at 1, 2,
4, 6, 9, and 12 months during routine health visits. Mean
compliance with supplementation was 85% (SD 12).
European Journal of Nutrition (2021) 60:4083–4091 4085

Follow‑up study
Between December 2017 and June 2018, mothers in the
original trial were contacted and invited to enroll in the
neurodevelopmental study when their child was 36 months
of age. Figure 1 shows the flow chart of participation from
the original trial to the current follow-up study. Reasons
for excluding children in the follow-up study were unwill-
ingness to participate, change of city, loss of contact, and
history of seizure. We re-enrolled 128 children whose
mothers provided informed consent to participate in this
follow-up assessment and a total of 122 children provided

220 mother-infant pairs enrolled during 3-5 days postpartum

At 3-5 days postpartum

40 mother-infant pairs
declined to participate

180 mother-infant pairs randomly assigned

60 pairs allocated to 300 60 pairs allocated to 150 60 pairs allocated to

µg I /d group µg I /d group placebo group
Followed until 1 year

At age 12 months

50 pairs completed follow up 43 pairs completed follow up 51 pairs completed follow up

Followed until 3 years

At age 36 months

4 ineligible for follow-up 7 ineligible for follow-up 5 ineligible for follow-up

46 included in 36 included in 46 included in

neurodevelopmental study neurodevelopmental study neurodevelopmental study

4 excluded due to
1 excluded due to lack of 1 excluded due to child
unwillingness to continue
child cooperation illness
collaboration

45 completed the study 35 completed the study 42 completed the study

Fig. 1  Flow chart of participation from the original trial to the current follow-up study

13
4086
neurodevelopmental data as follows: 300 µg/d iodine group:
45; 150 µg/d iodine group: 35; and placebo group: 42. With-
drawal from participation was mostly attributed to unwilling-
ness to continue collaboration (n = 1), child illness (n = 1),
or lack of child cooperation (n = 6). Structured interviews
were conducted to collect information on household demo-
graphic and socioeconomic data (including parents’ age,
education, and occupation and child kindergarten attend-
ance) and detailed medical history (including that of severe
illness and hospitalization). Ethical approval for the follow-
up study was obtained from the ethics committee of Tehran
University of Medical Sciences.
For neurodevelopment assessment, the children, accom-
panied by their mothers, were provided free transportation
to a central health care center and were assessed privately
in a test room to reduce distractions. The Bayley Scales
of Infant and Toddler Development, third edition (also
known as Bayley-III) was administrated by two trained and
experienced staff members who were blinded to the treat-
ment group assignment. Neurocognitive development was
assessed on three key scales: (1) cognitive, (2) language
(including the receptive communication and expressive
communication subsets), and (3) motor (including the fine
motor and gross motor subsets) using items administered to
the child. The social-emotional and adaptive behavior scales
of Bayley-III were not administered, as these items have not
been standardized for Iranian culture. Validity and reliability
of the Iranian version of the Bayley-III had been previously
determined and this test is confirmed to be appropriate for
Persian-speaking children aged 1–42 months [18]. Briefly,
the cognition scale of the Bayley-III assessed the child’s
performance in several cognitive areas, such as exploration
and manipulation, object relatedness, concept formation,
and memory. The receptive communication subset included
items that assessed child’s vocabulary development related
to objects and pictures, social referencing, and verbal com-
prehension. The expressive communication subset included
items that assess child’s preverbal communications and
vocabulary development. The fine and gross motor subsets
were associated with child’s quality of movement, axial
motor abilities, and coordination. The original test scores
were converted to composite scores that are age-standard-
ized with a normative mean of 100 and standard deviation
of 15. Bayley-III composite scores of < 85 were classified as
neurodevelopmental delay. We planned to assess childhood
neurodevelopment at 36 months of age, but the children were
assessed at a mean age of 39.7 months due to logistical study
delays.
Statistical analysis
The frequency distribution (percentage), mean [standard
deviation (SD)], and median [interquartile range (IQR)]
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European Journal of Nutrition (2021) 60:4083–4091
were expressed as categorical and continuous variables,
and normality was assessed by the Kolmogorov-Smirnove
test and a histogram chart. Non- and normally distributed
variables within groups (i.e., placebo, 150 µg/d iodine, or
300 µg/d iodine) were compared using Kruskal–Wallis and
ANOVA, respectively. Significant differences in categori-
cal variables were determined using chi-square analysis, Phi
coefficient and Cramer’s V measures. Linear mixed-model
analysis was used to assess iodine supplement dose effects
on child cognitive, language, and motor development. For
each continuous outcome variable, a separate mixed model
was derived with the fixed effect for treatment group and
participants as the random effect. Covariates included in the
neurodevelopmental analyses were: maternal age, education,
occupation, gestational age, child’s birth weight, sex, age,
and kindergarten attendance. All statistical analyses were
performed using Stata software version 12.0 (StataCorp,
College Station, TX, USA). A two-tailed P value < 0.05 was
considered statistically significant.
Results
Baseline characteristics of children and their mothers
included in the neurodevelopmental assessment are pre-
sented in Table 1. Characteristics of both children and
mothers at the enrollment did not differ among treatment
groups, except for date of last pregnancy. Mothers in the
300 µg/d iodine group had shorter interpregnancy interval,
compared to those in the 150 µg/d iodine or placebo groups
(P = 0.028). Medical history and kindergarten attendance
during the follow-up period did not vary by study group.
No significant differences were found in demographic or
baseline biochemical characteristics between children who
were followed-up and those who were not followed-up (data
not shown).
Figure 2 shows the mean Bayley-III subscales (cogni-
tion, expressive communication, receptive communica-
tion, fine motor and gross motor) and composite scores
(cognitive, language, and motor) of children at 36 months
in the three intervention groups. The mean (SD) cogni-
tive, language, and motor development in different groups
were: 300 µg iodine/d group: 101.2 (8.8), 101.1 (12.6),
and 93.2 (12.8); 150 µg iodine/d group: 102.8 (13.2), 99.8
(14.5), and 96.3 (14.5); and placebo group: 99.2 (10.5),
99.2 (13.9), and 91.0 (16.4), respectively. There were no
significant differences in any of the subscales or composite
scores of Bayley-III between the children of mothers who
received different doses of iodine supplements and those
who received placebo during lactation. Frequency of neu-
rodevelopmental delays in cognitive, language, and motor
domains in the treatment groups were: 300 µg iodine/d
group: 2.2, 8.9, and 22.2%; 150 µg iodine/d group: 8.6,
European Journal of Nutrition (2021) 60:4083–4091 4087

Table 1  Baseline characteristics Characteristics Treatment groups

of children and their mothers
included in neurodevelopmental 300 µg I/d 150 µg I/d Placebo
study by treatment groups (n = 45) (n = 35) (n = 42)

Childrena
Sex
Boy 29 (64.4) 20 (57.1) 21 (50.0)
Girl 16 (35.6) 15 (42.9) 21 (50.0)
Birth weight (g) 3310 ± 446 3375 ± 381 3391 ± 395
Birth length (cm) 50.3 ± 2.0 50.1 ± 1.9 50.1 ± 2.5
Birth head circumference (cm) 34.8 ± 1.4 35.4 ± 1.3 35.2 ± 1.2
Weight-for- age Z score − 0.02 ± 0.92 0.15 ± 0.85 0.18 ± 0.82
Weight-for- length Z score − 0.43 ± 1.41 − 0.07 ± 1.23 − 0.16 ± 1.37
Length-for- age Z score 0.36 ± 1.06 0.31 ± 1.08 0.33 ± 1.33
Head circumference-for- age Z score 0.51 ± 1.17 0.96 ± 1.02 0.84 ± 1.04
Thyrotropin (mIU/l) 1.00 (0.40–1.80) 1.40 (0.80–2.30) 0.90 (0.47–1.32)
Urinary iodine concentration (µg/l) 228.5 (72.5–283.2) 121.5 (45.8–281.0) 174.6 (85.6–395.3)
Mothersa
Age (yr) 27.5 ± 4.5 28.6 ± 5.0 29.2 ± 4.7
Education degree
Primary 11 (24.4) 11 (31.4) 19 (46.3)
Secondary 26 (57.8) 17 (48.6) 14 (31.4)
Higher 8 (17.8) 7 (20.0) 8 (19.5)
Occupation
Employee 3 (6.7) 3 (8.6) 1 (2.4)
Housewives 42 (93.3) 32 (91.4) 41 (97.6)
Parity
Primiparity 24 (53.3) 12 (34.3) 14 (33.3)
Multiparity 21 (46.7) 23 (65.7) 28 (66.7)
Date of last pregnancy (yr) 2.2 ± 2.9 4.3 ± 4.0 4.6 ± 5.0
Gestational age (wk) 37.9 ± 2.0 38.1 ± 1.6 38.3 ± 1.9

Values are median [interquartile range (IQR)], mean ± SD, or n (%), unless otherwise stated
a
No significant differences were found in baseline characteristics among the treatment groups, except for
date of last pregnancy

11.4, and 25.7%; and placebo group: 2.4, 11.9, and 23.8%,
respectively; the differences among the three groups were
not statistically significant (Table 2).
The effects of different doses of iodine supplementation
during lactation on child cognitive, language, and motor
development at 36 months, using the linear mixed-model
analysis, are shown in Table 3. Cognitive scores were
significantly higher in children whose mothers received
150 µg iodine/d compared to children whose mothers
received placebo (β = 4.43; 95% CI 0.38, 8.47; P = 0.032).
However, supplementation of 150 µg iodine/d in mothers
was not associated with beneficial effects on language or
motor development in children. No significant differences
in cognitive, language, and motor scores were observed
between children whose mothers received 300 µg iodine/d
and those whose mothers received 150 µg iodine/d or
placebo.
Discussion
To the best of our knowledge, this study is the first to exam-
ine the effects of maternal iodine supplementation during
lactation on neurocognitive development in children at
36 months of age. In this randomized placebo-controlled
trial, we found that children whose mothers received 150 µg
iodine/d had significantly better scores in cognitive, but not
in motor or language, development than control children
whose mothers received placebo. However, supplementation
of lactating mothers with 300 µg iodine/d had no effect in
any of the neurodevelopmental outcomes in children, com-
pared to the 150 µg iodine/d and placebo groups.
It is well known that brain and central nervous system
develops rapidly in utero and up to age 3 years. The majority
of prior studies have focused on the adverse effects of iodine
deficiency during pregnancy on child neurodevelopment

13
4088 European Journal of Nutrition (2021) 60:4083–4091

a 20 for optimal brain growth and cognitive development. In a

300 µg I/d study by Wu et al., the only prior study available, higher
150 µg I/d
breast milk iodine concentrations at few days postpartum
BSITD III scores

15 Placebo
were associated with better infant motor development, spe-
10 cifically gross motor function [17]. It has been shown that
lactating mothers with higher iodine intakes had a greater
5 fractional iodine excretion in their breast milk, however,
with inadequate iodine intake, a relatively constant pro-
0 portion (approximately 33%) of total iodine was excreted
in breast milk [22]. We previously observed significantly
ve

or
om

or
m

ot
ot
iti

co

sc

m
m
gn

re
p

increased breast milk iodine concentration in mothers who

ss
ne
Co

ce

ro
Fi
Ex
Re

G
received 300 or 150 µg iodine/d compared to placebo; how-
b ever, neurocognitive development of children showed incon-
150
300 µg I/d sistent results between the two supplemented groups. This
150 µg I/d interesting observation indicates that child neurodevelop-
BSITD III scores

100
Placebo mental outcomes may vary across different levels of breast
milk iodine concentration.
Studies in iodine-deficient school-aged children have
clearly shown that iodine supplementation was associated
50

with improvement in cognitive function [23]; however, data

0 regarding the effect of iodine supplementation for mildly-
Cognitive Language Motor
moderately iodine deficient pregnant women for child neu-
Fig. 2  Comparison of neurodevelopmental scores in children at age rocognitive development are still inconclusive. In a recent
36 months by treatment groups. a BSITD-III scaled scores; b BSITD- meta-analysis of randomized clinical trials by Dineva et al.
III composite scores. The box represents the 25th to the 75th percen-
tile of the data. The solid line inside the box indicates the median no differences were found in cognitive, language, or motor
value and the dot beside the line indicates the mean value. BSITD scores between children born to women who received iodine
Bayley Scales of Infant and Toddler Development supplementation during pregnancy and those born to non-
supplemented women [11]. Some studies demonstrated
that the effect of iodine on the neurocognitive develop-
Table 2  Frequency of neurodevelopmental delay (< 85) in children at ment of children varies at different stages of pregnancy and
age 36 months by treatment groups emphasized the necessity of initiating iodine supplementa-
Outcome Treatment groups tion before or as early as possible during the pregnancy to
ensure the adequacy of fetal neurodevelopment [24]. Sev-
300 µg I/d 150 µg I/d Placebo
(n = 45) (n = 35) (n = 42) eral medical and public health advisory groups have rec-
ommended continuation of iodine supplementation during
BSITD-III, cognitive score lactation, however, its necessity for optimizing child neu-
Normal 44 (97.8)ab 32 (91.4) 41 (97.6) rodevelopmental outcomes is yet to be investigated. In our
Cognitive delay 1 (2.2) 3 (8.6) 1 (2.4) previous study, the baseline median UIC in lactating moth-
BSITD-III, language score ers was < 100 µg/l in all treatment groups [300 µg iodine/d
Normal 41 (91.1)ab 31 (88.6) 37 (88.1) group: 70 (40–116) µg/l; 150 µg iodine/d group: 71 (38–111)
Language delay 4 (8.9) 4 (11.4) 5 (11.9) µg/l; and placebo group: 97 (45–154) µg/l]. However, on
BSITD-III, motor score the basis of urinary iodine levels in their infants indicating
Normal 35 (77.8)ab 26 (74.3) 32 (76.2) iodine sufficiency, we declared that lactating mothers resid-
Motor delay 10 (22.2) 9 (25.7) 10 (23.8) ing in an iodine sufficient area with effective salt iodization
BSITD-III Bayley Scales of infant and Toddler Development-III program have no need for iodine supplementation [16]. The
a
Values are number and percentage in parenthesis present follow-up study showed that supplementation of lac-
b
No significant differences were found among the treatment groups tating mothers with 150 µg iodine/d had a beneficial effect
on cognitive function in children at age 36 months.
Few studies to date have explored the effect of iodine
[19–21]. However, the effect of iodine status during lac- excess on child neurocognitive development. For instance,
tation on infant/child neurocognitive outcomes remains Aakre et al. investigated early childhood neurodevelopmental
poorly understood. Exclusively breastfed infants are entirely status in association with iodine excess in a cross-sectional
dependent on adequate iodine concentration in breast milk study. The authors concluded that high iodine intakes can be

13
European Journal of Nutrition (2021) 60:4083–4091
Table 3  Effects of different doses of iodine supplementation during lactation on neurodevelopmental outcomes in children at age 36 months
a key contributor to thyroid dysfunction and poorer devel-
opmental status in young children (aged 18–48 months), as
assessed using the Ages and Stages Questionnaires, third
edition [25]. However, in this present study, excessive iodine
intakes in infants whose mothers received 300 µg iodine/d
during lactation had no observed effect on neurocognitive
development at 36 months of age. Available studies have
shown inconsistent results regarding the effect of excessive
iodine intake on thyroid function during infancy. In some,
excess iodine intakes were associated with a high prevalence
of subclinical hypothyroidism [26, 27], while others reported
no thyroid dysfunction in infants exposed to high doses of
iodine [28]. However, the long-term consequences are still
unknown and need further investigations.
It is noteworthy that although median UIC is a well-
accepted, cost-efficient, and easily measured indicator for
determining iodine status at the population level, it reflects
iodine intakes over a short time period and the intra-individ-
ual variation is huge [29]. Other recommended markers for
iodine status include thyroid volume—a sensitive marker for
severe iodine deficiency over a period of months or years,
and thyroid hormones, such as thyroid stimulating hormone,
thyroxine, and tri-iodothyronine, which are weak markers
of iodine status because the levels typically remain within
the normal reference range during mild-to-moderate iodine
deficiency [30]. Recent studies suggest that thyroglobulin, a
thyroid-specific protein, may be a better indicator of iodine
4089
status [31, 32]; however, no consensus has been reached
regarding the optimal cutoff value for thyroglobulin concen-
tration to indicate iodine status during pregnancy or lacta-
tion. Additionally, its association with neurodevelopmental
outcomes remains unclear.
The main strength of the current study is the randomized
controlled trial design with 3 year follow-up that enabled
us to demonstrate a causative link between maternal iodine
supplementation during lactation and subsequent neurocog-
nitive development in children. However, there are some
limitations that need to be acknowledged. Because the final
sample size in each treatment group was relatively small,
caution should be taken in interpretation of these results.
Although randomization should have minimized the effect
of known and unknown confounders, we did not measure
intelligence of mothers and household income, which are
known to influence child neurodevelopmental outcomes.
Child neurocognitive development was evaluated using
an internationally recognized tool; measuring the specific
domains of cognitive and psychomotor development using
more precise methods may provide more accurate data in
this regard.
In conclusion, the present study demonstrated that mater-
nal iodine supplementation with 150 µg/d during lactation
may have a beneficial effect on child cognitive develop-
ment. There was no evidence of either improved or delayed
neurodevelopmental outcomes in children whose mothers
13
4090
received iodine supplement at doses higher than recom-
mended. To the best of our knowledge, no prior study has
been conducted to assess the neurodevelopmental effects of
iodine supplementation during lactation; therefore, it is dif-
ficult to draw definitive conclusions at present. Further ran-
domized controlled trials involving larger sample sizes and
longer follow-up periods are needed to confirm our findings
and examine whether the benefits of iodine supplementation
persist into the school years and beyond.
Acknowledgements This study was supported by financial grant from
Tehran University of Medical Sciences (grant number 97-02-91-37843)
and Research Institute for Endocrine Sciences, Shahid Beheshti Univer-
sity of Medical Sciences (grant number 480), Tehran, Iran.
Authors contribution PN contributed to design the study concept, data
collection and interpretation, and writing, reading, and final approval
of the manuscript; JT contributed to the data analysis and interpreta-
tion, and writing, reading and final approval of the manuscript; ENP
contributed to design the study concept, and writing, reading, and final
approval of the manuscript; ZZ and TT contributed to data collection
and interpretation, and writing, reading and final approval of the manu-
script; PM and FA supervised the study procedure and contributed to
writing, reading and final approval of the manuscript.
Funding This study was supported by financial grant from Tehran
University of Medical Sciences (grant number 97–02-91–37843) and
Research Institute for Endocrine Sciences, Shahid Beheshti University
of Medical Sciences (grant number 480), Tehran, Iran.
Availability of data and material The data that support the findings
of this study are available on request from the corresponding authors.
Declarations
Conflict of interest None of the authors has any personal or financial
conflicts of interest.
Ethics approval Ethical approval for the follow-up study was obtained
from the ethics committee of Tehran University of Medical Sciences.
Consent to participate Written informed consent was obtained after the
study protocol and objectives had been fully explained to the parents
of children.
Consent for publication The corresponding authors had final respon-
sibility for the decision to submit for publication.
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