This month, the AAP published a clinical report representing the committee on nutrition, urging pediatricians and parents to work together to improve rates of iron deficiency in this country. The reason: iron deficiency is one of the more common problems among children but it frequently goes undetected. We can’t see it, smell it, or detect it easily on exam or with one simple blood study. Oddly enough, it’s complicated to determine an infant/child’s iron status.
New research finds that deficiency of iron, particularly at young ages (0-3 years)–when the brain is forming and growing rapidly–may have irreversible effects on cognitive and behavioral development. Although the majority of infants and children are not deficient in iron, between 5% to 15% of toddlers are deficient. There are no great studies (believe it or not) telling us exactly what percent of infants are truly deficient.
Don’t go nuts about this and don’t let this scare you. You only need to make changes now, not look back and worry. First of all, let me put this in perspective: iron deficiency used to be a bigger problem than it is now. Prior to the 1970’s (when iron was added to infant formula) rates of deficiency were around 30-40% of babies. Breast-fed infants are at higher risk (versus formula fed babes) of being iron deficient if there is delay in introducing solid foods. So when the pediatrician has mentioned waiting until 6 months for solids, we neglected to prioritize iron.
We care about iron deficiency because it can cause two major problems:
- Iron deficiency anemia (small, pale red blood cells)
- Slowed or depressed cognitive and behavioral development. The first 3 years of life are critical for brain development and there is new research that iron status, starting in infancy, is essential for later cognitive performance. Think of “cognitive performance” as seeing well, reasoning, remembering, and interacting with others. So this stuff matters.
My biggest hesitation when I read the report the first time was that we were sending yet another message to breast-feeding moms that their milk wasn’t enough (ie your baby may need a supplement of iron in addition to that vitamin D). Furthermore the recommendations are filled with testing, re-testing, and follow-up evaluations that may be confusing and scary for families. Yet after numerous conversations with other doctors who were initially skeptical, and about 4 personal reads of the report, I have come to the same conclusion as those with who I spoke: We need to protect infants from deficiency of iron and we need to do more comprehensive screening of those babies graduating into toddlerhood. So some facts and explanations:
- Iron is important not only for building strong blood (seriously, I mean this) but also allowing a productive, smart, well-connected brain to form. It needs to be around in ample (but not too much) supply in the first 3 years.
- Iron is found readily in fortified infant formula, fortified baby and adult cereals, meats (red meat is best), dark leafy veggies, fish, soybeans like edamame, molasses, beans and others.
Babies & Toddlers at highest risk for complications:
- Prematurity or low birth-weight babies. Why: Iron passes from mom to baby most in the 3rd trimester. If babies come out early they are born with less iron stores.
- Lead exposure. Why: Iron deficiency increases the absorption of lead so could make things worse.
- Exclusive breastfeeding past 4 months of age without iron supplements. Why: After 4 months of age, the stores of iron are used up in baby and human breastmilk contains very little iron. If a baby is weaned to foods that don’t include iron-fortified cereals or iron-rich foods, they are at higher risk.
- Infants with special health care needs might also be at risk. Why: nutritional intake, their use of iron, and the treatments they have received.
- Children of low economic status, particularly those of Mexican American descent are at higher risk. Why: unclear. Possibly cultural food choices, access to fortified foods, variations of the diet in some homes.
The AAP Recommendations:
- Newborns: Term, healthy infants have sufficient iron for the first 4 months of life. Because human breast milk contains very little iron, breastfed infants should be supplemented with 1 mg/kg per day of oral iron from 4 months of age until iron-rich foods (such as iron-fortified cereals) are introduced.
- Infants 6 to 12 months of age need 11 mg per day of iron. When infants are given complementary foods, red meat and vegetables with high iron content should be introduced early. Liquid iron supplements can be used if iron needs are not met by formula and complementary foods.
- Toddlers 1 to 3 years of age need 7 mg per day of iron. It is best if this comes from foods such as red meats, iron-rich vegetables, and fruits with vitamin C, which enhance iron absorption. Liquid supplements and chewable multivitamins can also be used.
- Preemies: All preterm infants (born before 37 weeks) should have at least 2 mg/kg of iron per day until 12 months of age, which is the amount of iron in iron-fortified formulas. Preterm infants fed human milk should receive an iron supplement of 2 mg/kg per day by 1 month of age; this should be continued until the infant is weaned to iron-fortified formula or begins eating foods that supply the required 2 mg/kg of iron.
- All Universal screening for anemia should be performed at 12 months of age during routine care taking into account risks (that I listed above) when interpreting the labs.
Overwhelming, yes. Doable, yes.
A quick translation: Mama Doc’s Take Home On Iron
- You don’t have to count milligrams of iron (this seems nearly impossible) intake in your child like you count calories (if you do). But you may want to talk with your pediatrician if you are exclusively breast-feeding your baby, have a preemie, are on WIC, or are of Mexican American background.
- Talk with your pediatrician at the next check up about iron intake in your infant. You don’t have to use a supplement if you can offer iron-rich foods in the diet. Review what your baby eats with your pediatrician. Together you can decide if you need to start supplements of liquid iron. If your baby is formula fed or gets more than 1/2 of their milk from formula, there is no need to supplement.
- Babies should be screened between 9-12 months of age with a blood test (hemoglobin concentration). Talk with your pediatrician about your baby’s risk for deficiency. If the test comes back with a low level, your baby will likely need a follow-up blood study to confirm iron deficiency exists.
- Don’t worry about the past and your baby’s intake. I certainly don’t think my boys got the iron that these recommendations cover. So, I’m moving forward as of today, making different choices. You can, too.
Questions (or if you want to rant about the length of this post) leave a comment below. We’ll work on this together.
Wendy Sue Swanson, MD says
Please be nice about the face on that screen shot for the video. Talk about a bad face day…
I’m a new reader of your blog (found it from the skeptical OB blog). Iron deficiency is something I have always worried about with my kids (age 1 and 3). Where I live (Norway), there is a lot of information about how kids might be iron deficient and that we need to feed them high iron foods, but no screening for iron deficiency.
There are two things that I have heard before that differ from your post and I wondered if they are changed due to new research, or if they where never true in the first place. I heard that:
– A babies iron stores run out at around 6 months (rather than 4 months).
– Breast milk does not contain much iron, but it is very well absorbed so that it still counts as a good source of iron.
I think it is really difficult to come close to estimating how much iron my kids get since different foods contain different amounts of iron, vitamin c increases absorbtion, milk, egg white and tannin decrease absorbtion, and the kids eat random quantiies of all food offered. Can you offer any more tips for this, or an example of what they would have to eat in a day to cover the requirements?
Wendy Sue Swanson, MD says
Boble–Thanks for your comment. The 4-6month range is just that, a range. So noting that infants need more iron at 4 or 6 months are both correct.
I agree—I think it’s really difficult to estimate how much iron kids are getting from diet. Counting milligrams is a really impractical thing to mention. Hence why I stayed away from that in the post.
Example of food sources & iron content, found in the study ( in table 3 on page 6). But short synopsis of examples of iron-rich foods:
baby food chicken (2.5oz) gives 1 mg iron
baby food beef (2.5 oz) gives 0.7mg iron
baby brown rice cereal (instant) 1 tablespoon gives 1.8mg iron
baby rice cereal (instant) 1 tablespoon gives 1.2mg iron
chicken liver (who eats this?) gives 9.9 mg iron
turkey meat (dark meat) 3 oz gives (size of deck of cards!) 2 mg iron
apricots–dehydrated 1/2 cup gives 3.8mg iron
oatmeal–instant 1 cup gives 14 mg iron (!!)
molasses 2 tbsp (as Viki mentioned) gives 7.4mg iron
raisins 1/2 cup gives 1.6mg iron
Those are some examples. Take a peek at the study for the large table. But be careful, meat is listed as 3 oz servings sizes (deck of card sized) and not what most toddlers eat!
Hope that helps!
As a breastfeeding mom, I agree that it sends yet another message that our milk isn’t good enough. I’d be interested to know more about the study this was based on. Were those 5-15% of iron deficient children breastfed, formula fed or both? Breast milk does have fairly low iron content, but that’s because the iron in it is so well absorbed by the baby. So were the mother’s levels checked if baby was deficient?
Wendy Sue Swanson, MD says
Jeffie, the clinical report I’m detailing here isn’t one study. Rather it’s a committee’s recommendation. They reference 77 different studies in their report. So in the data on toddlers (age 1-3)I mentioned is from the National Health and Nutrition Examination Survey (1999-2002) for iron deficiency and iron deficiency anemia. Children are grouped by background (poverty, enrolled in WIC, and ethnicity). Highest risk groups were those enrolled in WIC (10.7% were iron deficient) and Mexican American (13.9% iron deficient). I am unsure about the breakdown of those groups in regards to breastfeeding status in infancy or toddlerhood.
And yes, iron in breastmilk is well absorbed by babies. The debate is after iron stores become more deplete somewhere between 4-6 mo. In the report, AAP notes that after 6 months of age, exclusive breastfeeding is associated with increased risk of iron deficiency anemia at 9 mo of age (data from study). Also note a double blind study (Friel et al) that found exclusively breastfed infants supplemented with iron between 1 and 6 moths of age had higher hemoglobin concentration than their non-supplemented peers when checked at 6mo. Makes sense but may not necessarily prove its necessary .
Of course, another solution to this concern at 4-6 months of age is to offer iron fortified cereals at 4 months of age instead of supplements of iron.
I really wish my pediatrician would have discussed iron deficiency with me prior to my son’s 12 month visit. I choose not to use any formulas, baby cereals, baby foods, “toddler” snacks, etc. I am having a very difficult time accepting the fact my son’s Hgb was 10.5 at his appointment, and the medical assistant (not an RN or provider) told me to “just go get a multi-vitamin with iron” to start him on. What if I don’t want my kid on vitamins? I know I’m being “that mom”. Had I known how big of a deal this was going to be, I would have tried to figure out how to make chicken liver, added some molasses to his oatmeal, etc.
I don’t think this knocks breastfeeding as much as it underscores the importance of eating the most nutritious foods you can. I was severely anemic after my second child was born. (Hematocrit dropped from 38 to 24.) I built up my iron in a few months through these simple changes:
* 100% whole grains, flours, cereals. (Foods have to be enriched when the goodness is processed out. What is added back is mandated by law once a specific deficiency from the processing is identified in the population. Iron, folate, niacin, etc were all added back individually. You can skip the deficiency by eating the unprocessed grain.)
* Meat & eggs on a daily basis. (Pasture meats where possible to add healthier fats.)
* Blackstrap molasses as sweetener. (100% DV of iron, calcium, potassium, phosphorus in 3 tbsp.)
* Seasonal produce. All the winter squash, chard, and beets had a positive contribution. Especially since I wouldn’t have chosen those foods over frozen broccoli in winter in the past.
My second baby was screened because he was at risk – premature, anemic mom, breastfed, no formula or iron supp, absorption problems, and he was fine. He’s intolerant of milk & soy, so maybe he absorbed more of what’s available in the foods we introduced?
Aha! Mystery solved. I skipped rice and fed both my babies oatmeal starting at 5-6 months. They still eat it everyday. Popeye better change his tune!!
Thanks for putting iron in the lineup. I thought iron deficiency was near impossible except perhaps for the pickiest of eaters.
Annie @ PhD in Parenting says
What I worry about with these types of directives is that too many parents will worry unnecessarily and make changes that may cause more harm than good. I wish that it was easier/more routine to be able to test for things like Vitamin D levels, iron levels, etc.
Just to clarify a fine point–you don’t need to be anemic to be iron deficient. The hemoglobin alone will not determine iron deficiency unless it’s severe enough to cause anemia. Iron deficiency without anemia can still cause developmental/cognitive problems. There needs to be a specific iron determination along with that hemoglobin to be a truly useful screen. (at 9-12 mos) Otherwise–thanks for a great post!!!
Wendy Sue Swanson, MD says
I agree, Katie. That is the problem with testing for IDA (iron def anemia) at 9-12 months and not iron levels, themselves. If you read the clinical report, they address not only the distinction between the two, but also limitations in testing. What I said in the first part of the post, remains, there is not one easy test to check for “iron status” rather we use dietary history, past medical history, and risk groups to help us guide how we evaluate, screen, and supplement children. If you concerns for iron deficiency (because of risk) or IDA, you can go straight and order a ferritin (with quant CRP for reference) as well.
Hello Dr. Swanson, you diagnosed my son T last week with Iron-deficiency anemia while I was reading online, I accidently found your blog. I had never really heard about it before. But now I have so many questions in my head.
His diagnose does explain a lot of his attitude and behaviors in the last 3 months and it really makes us feel better to know why and to work towards getting him better. Nevertheless, after reading so many articles it makes me wonder about the possible consequences of IDA in the long term. I read on your blog and other articles that some of the possible consequences of IDA are “slowed or depressed cognitive and behavioral development” and it’s also explained that sometimes those are not reversible.
When and/or how do I know if it’s already too late for T. or if it will be reversible?
How do we know if he’s already suffering from those symptoms or not?
I always thaught that he was of a shy nature but now it makes me questions so many things he does in social situations. There are so many other variables in his environment how do I find out which ones are related to the IDA? I guess waiting is one option, but like most parent I guess, I don’t want to wait around.
I am in your exact position! What I thought was my boy’s passive nature and all. How is your baby now? Did he catch up?
Wendy Sue Swanson, MD says
First of all, you are doing what you need to do by seeking care, reading about IDA and learning about replacement with iron. It is difficult to know long term effects right now and what matters is what steps you take from today forward. Putting iron back into stores for a child is exactly what you need to do in the face of iron deficiency anemia. So yes, IDA is reversible.
I really don’t think there is data to suggest IDA has personality effects (shyness).
Try to give yourselves space, patience, and time.
Wendy Sue Swanson, MD says
Here’s a great interview about anemia in general (and some specific about iron deficiency anemia) with Dr Dana Matthews, a hematologist at Children’s.
And the response to the report… https://pediatrics.aappublications.org/cgi/eletters/peds.2010-2576v1
Thanks Claire for adding your post. It’s interesting that no further posts were added.
Wendy Sue Swanson, MD says
Do you mean it’s interesting that no other posts were written meaning this one should have been changed? I don’t think it should be changed. My post reflects both perspectives, that of the committee on nutrition and that of the committee on breast feeding.
The editorial that Claire linked is written by a different but equally respected council on the AAP to the authors of the guidelines I reviewed above. One committee is not more “right” or correct than another. Simply, this is a perfect example of how and why different physicians with different specialties and expertise will come to disagree on certain recommendations. This disagreement is essential in helping us all understand how to council families.
In the “Quick Translation” section in my post above, look at the statement in bold. I didn’t say that all babies should be supplemented with iron. Because frankly, that’s not my take. As I said in point #2 and #3 above, if your baby is lucky enough to be exclusively breast fed, you can consider adding iron rich foods at 4 months or screening at 9 months if you’re concerned your baby may not be getting the iron you need. Or particularly if you’re in a high risk category. Going immediately to iron supplementation is not the only way to prevent iron deficiency, as the editorial pointed out. So delayed cord clamping, iron rich food between 4 and 12 months, and more ongoing research on the bio-availability of iron in breast milk versus iron in fortified formula needs to continue to be a part of the discussion.
I had a baby at 36 w 2 d in 2010 and was told by her nutritionist she needed iron but my pediatrician nixed the idea and told me breast milk has better iron transfer, which would be interfered with by iron supplementation. I have even seen this assertion on some reputable websites such as Kelly mom, but now realize it must not be true b/c of the new recommendations.
I finally decided her nutritionist seemed to know more and started iron in month 4, but am so sorry for my little baby I didn’t start sooner.
Why would my pediatrician care one way or the other whether I gave an iron supplement? What happened to \first, do no harm\? Sigh.
Does this apply to formula-fed babies? Formula tends to have iron in it, and I was wondering if this is still a concern. Thanks so much!
Debra Tate Espinosa says
I’m finding this post in late 2014. Has the researches changed since this article was written in 2010?
My baby was born at 34 weeks 4 days and the neonatal physicians recommended supplementing with formula for 6-12 months but we stopped around 3 months due to concerns over formula. Baby is 5 months old now and has not started solids.
I have a 5 week old taking Fer in Sol and it upsets her, would switching to Palafer solution be better??
I know thjs article is old but hoping to get some reassurance. My 9 month old just had his hemaglobin tested and it is 8.7 with ferritin of 7. Pretty scared mom here. I had no idea as it was routine testing. I am worried about,his development as he is slightly behing. Do you think he has a high chance of autism or other problems in the future from this? He has been exclusively breast fed but started food at 5 months.No one ever mentioned iron supplementation until now….too late!!! So worried.
Sana Q says
Thank you for this informative article. My paediatrician recommended that we start baby-led-weaning. My baby is now 8 months old and barely takes in a mouthful of food, although he enjoys chewing it and then spitting it (mostly) out. From personal research, I learned that he should be having high-iron food sources.
What is your take on baby-led-weaning in light of the possibility of low iron intake?
As well, my 8 month old is gaining weight normally, is active, alert and happy. Is it possible for him to have low iron without displaying symptoms of anemia?
My 5 week old has low iron levels and are reducing. He was born at 39 weeks and was a healthy weight and exclusively breastfed. He’s putting on a lb a week and other than a cold since a few days old he seems fine. Everything I have read has said he should be getting enough until he is 4 months old but he can’t be. Should I switch to formula?
My daughter has been breastfed exclusively and started eating only iron-rich complementary foods around 5 months of age. I did delayed cord clamping and she had borderline high hematocrit at birth, so I wasn’t particularly worried about her iron status until the past couple months. I’ve decided to supplement because her cognitive development seemed to slow a bit, ie, she met milestones extremely early (as is common in my family) until about 9 months of age, then slowed down exponentially and did not advance as expected, though still in the range of normal, and she’s been aggressive with biting, hitting, etc; her nails are also looking a bit flat. I can’t seem to find any information if supplementing at her age (14 months) would reverse the mild issues with cognitive function. I feel really guilty for not supplementing earlier; I did feed her the proper foods, but she can be a light eater. She’s definitely nowhere near anemic, but I’ve read that mild iron deficiency can escape detection.
Home Hannah says
My daughter is 4 and her iron is 14!! M worried a lot!! Please guide me now giving her regulatory a full cup of cooked 1 cup lentils with squeezed Lemon and formulae milk. Rest she is a picky eater. She has a lot of behavior issues screams all the time.
Kameron mary says
Hi, just wanted to know if a iron level of 9.9 on a 1 month old is excessively low and would cause the baby to bruse easy?
Tim Yaotome says
Oh no! I felt worried when you said that iron deficiency is a common problem among children. When you said that, I thought that I should send my daughter to a pediatric service right away. Doing this will help us know whether she has anemia or not and be able to know how to take care of her diet.