Childhood101

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Preventing Iron Deficiency in Toddlers

This post is by regular contributor Naomi Cook.

Two pregnancies, endless months of breastfeeding, running a couple of marathons and a lot of training in between left me a little lacking in the Iron Department. Iron deficiency makes me very tired, susceptible to infection and gives me tell tale dark circles under the eyes that even the best make up can’t hide. With a bit of effort however, my deficiency is pretty simple to overcome. But what about toddlers?  You may be surprised to learn that toddlers and preschoolers are most at risk of developing an iron deficiency over any other age group.

What is Iron Deficiency?
Iron is used in the body in a variety of different forms for a number of different metabolic and neurological processes. 3, 7 It is for example, used in the brain to help cells formulate the fatty sheath on nerves 3, 7; this makes neurological processing faster. It is also important for forming haemoglobin which is used in the blood to carry oxygen around the body.

Sustained erosion of iron stores can lead to Iron Deficiency Anaemia; this will impair oxygen transport around the body. But, very importantly, Iron Deficiency is thought to permanently effect the development of the brain of a young child;

“Recent studies show that even transient iron deficiency without anaemia (can result in) irreversible negative effects to the brain.” 1

Studies show that toddlers with iron deficiency and iron deficiency anaemia may suffer long term defects including cognitive, motor, emotional and behavioural changes. 2, 3, 5, 6, 7, 12 These include impaired learning ability, decreased academic achievement and lower scores for mental and motor development. 1, 2, 5 10

An individual with iron deficiency is also at increased risk of infection 1, 9

Why are toddlers at a risk of Iron Deficiency?
Natural Stores: At 6 months of age iron stores become depleted 10, 12, then the baby must consume enough dietary iron to prevent deficiency from occurring. 11

Diet: Toddlers can have poor dietary intake, 3, 7, 8 as well as fussy eating habits, poor appetites, they are also transitioning to an adult diet that may be lower in iron than their ‘fortified’ diet of infancy. 9 Meat intake also tends to be low in preschoolers. 9

Growth: Toddlers need more iron in relation to body size than at any other point in their lives due to their fast rate of growth. 2, 3, 7, 8, 9

Excess Consumption of Milk:
a. Exclusive breastfeeding beyond six months – without solid food intake
b. The introduction of cow’s milk as the main drink before twelve months of age 8, 11, 12 – cow’s milk is not fortified in iron like infant formula
c. The giving of milk and juice in a bottle after the age of 18 months – this leads to a higher consumption of milk/fluid resulting in a reduced appetite for solids. 2, 9, 10

Yikes! It ‘s pretty scary reading how vulnerable toddlers are to developing an iron deficiency, so what can we do to help prevent it;

Prevention and Iron Boosting Tips
1. Haem Iron found in red meat, poultry and fish is easier to absorb than Non-Haem Iron found in other foods.

2. Some iron rich foods include – red meat, egg yolk, lentils, wholegrain cereals, dried fruit such as apricots and figs, prune juice, tomato paste, baked beans, sweet potato and quinoa.

3. Be savvy: Develop a few tactics for iron rich meals/snacks. Eating iron rich food at the same time as a food high in calcium will hinder the body’s absorption process. 4 Eating iron rich food with vitamin C will facilitate iron absorption. 4, 9

  • For breakfast offer something rich in calcium like cheese on toast, fruit smoothie or yogurt rather than serving iron fortified cereal with milk. Then, offer the cereal as a ‘snack’ all by itself at morning tea. Put the “cereal crisps” in a little pot without the milk and give vitamin C rich orange juice as a drink. Or you could offer beans on wholegrain toast for breakfast with apple juice then offer milk or a yoghurt mid morning.
  • If serving meat or lentil soup for dinner, serve with vegetables and then fruit for dessert rather than yoghurt or ice cream. Save the yoghurt or milk as a bed time snack a little while later.
  • Bake vegan muffins with iron fortified cereal or cooked quinoa and dried fruit as ingredients. Experiment with non dairy cooking fats such as ‘coconut oil’ and nut/oat milks.
  • There are other inhibitors of iron absorption such as: Oxalates, Phytates, 12 Tannins, Polyphenols and phosphates. 9 Getting bogged down with these makes meal planning very difficult but something interesting to note is that high iron spinach is also very high in oxalates, making the iron very difficult to absorb.
  • If you are very concerned about how to increase your childs dietary iron, visiting a nutritionist for advice may be helpful.

4. Give iron fortified cereals to children whenever you can for as long as you can. Look for brands of porridge and cereals that are fortified.

5. Seek advice from your child’s doctor regarding appropriate iron rich supplements : There are currently some iron rich products available on the market suitable for children. “Spa Tone” 14 is an iron rich water, which according to the manufacturers is suitable from age two.  “Floradix” 15 is an iron and vitamin B rich supplement which manufacturers  state is suitable for over twelve months.

6. Aim to have your child drinking from a beaker rather than a bottle by 12-18 months of age. Ask your early childhood nurse or pediatrician about the daily recommended amounts of milk for your child so you avoid giving too much, or too little.

If you suspect that your toddler is low in iron you should take them to the doctor. Please note: Iron supplements in high doses are toxic. Only a doctor should ever recommend iron supplements for a child. Even at non-toxic doses iron supplements can have unpleasant gastro-intestinal side effects.

And You!
You may be lacking in the Iron Department too! If you are feeling lack lustre, why not get your own iron levels checked? As self sacrificing mums we all too frequently focus on the health of our children and forget our own.

Do you have any tips for iron rich meals and snacks suitable for the fussy toddler?

DISCLAIMER: The information contained in this article should NEVER be used as a substitute for the advice of a licensed physician. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please see a physician if you think you or your child are unwell. This author has no competing interests.

References

     

  1. Bamberg R (2008) Occurrence and Detection of Iron Deficiency Anaemia in Infants and Toddlers Clincial Laboratory Science: Anaemia in Selected Populations 21:4 pp225-232
  2. Brontanek J, Gosz J, Weitzman M, Flores G (2007) Iron Deficiency in Early Childhood in the United States: Risk Factors and Racial/Ethnic Disparities Pediatrics 120: 568-575
  3. Cleghorn G (2007) The Role of Red Meat in the diet for children and Adolescents Nutrition and Dietetics 64:4 pps141-s146
  4. Harris S (2002) The Effect of Calcium Consumption on Iron Status Nutrition in Clinical Care 5:5 pp231-235
  5. Hurrell R (2010) Use of Ferrous Fumarate to fortify food for infants and young children Nutrition Reviews 68:9 pp522-530
  6. Kumar K M (2001) Screening for Anaemia In Children: AAP Recommendations – A Critique Pediatrics 108:3 p1-2
  7. Lozoff B, Beard J, Connor J, Felt B, Georgieff M, Schallert T (2006) Long-Lasting Neural and Behavioural Effects of Iron Deficiency in Infancy Nutrition Reviews 64:5 pps34-s43
  8. Soh P, Ferguson E, McKenzie J, Homs M, Gibson R (2004) Iron Deficiency and Risk Factors for lower iron stores in 6-24 month old New Zealanders European Journal of Clinical Nutrition 58 pp71-79
  9. Stanner S (2003) Iron Deficiency in Infancy and Childhood British Nutrition Foundation: Nutrition Bulletin 28: pp221-225
  10. Sutcliffe T, Khambalia A, Westergard S, Jacobson S, Peer M, Parkin P (2006) Iron Depletion is associated with daytime bottle feeding in second and third years of life Archives of Pediatric and Adolescent Medicine 160:1114-1120
  11. Male C, Persson L, Freeman V, Guerra A, Van’t M, Hof, Haschke F, and the Euro-Growth Iron Study Group (2001) Prevalence of iron deficiency in 12-mo-old infants from 11 European areas and influence of dietary factors on iron status (Euro-Growth study) ACTA PÆDIATR 90 pp492-498
  12. Philips F (2005) Vegetarian Nutrition British Nutrition Foundation: Nutrition Bulletin 30 pp132-167
  13. Wharton 1999 Review: Iron Deficiency in Children Dectection and Prevention British Journal of Haematology 106: 270-280
  14. Spatone
  15. Floradix

 

Naomi Cook is a Masters qualified Registered Nurse with a passion for Health Education and Preventative Health Care, especially for mums and babies. Naomi is the lucky mum of two adorable little girls, a toddler and baby who are thriving off the wonderful Australian climate and lifestyle.

Read the comments or scroll down to add your own:

  1. Heather says

    Spinach, kale and other greens are also a good source of iron. We do green smoothies, which are healthy and tasty. I want to make a comment about the exlusive breastfeeding beyond six months, because it is actually quite healthy to do and I believe that babies who are breastfeed past six months are less at risk for iron deficiency than those fed formula (iron in iron-fortified formula is not very absorbable, only maybe 1 -7 % is absorbed). The current research indicates that a baby's iron stores should last between six and twelve months, depending upon the baby. The iron in breastmilk is better absorbed than that from other sources. The vitamin C and high lactose levels in breastmilk aid in iron absorption. The perctange of iron absorbed from breastmilk is 50 to 70 percent, so I don't think that breastfeed babies past 6 months of age would necessarily be at risk for iron deficiency. The original iron stores of a full-term healthy baby, combined with the better-absorbed iron in breastmilk, are usually enough to keep baby's hemoglobin levels within the normal range well into the second six months. A recent study (Dewey 2002) found that routine iron supplementation of breastfed babies with normal hemoglobin levels may present risks to the infant, including slower growth (length and head circumference) and increased risk of diarrhea. I just that was some additional information that should be given.. I don't want moms to freak out because they are breastfeeding their babies past 6 months without introducing solids (especially given the high incident of food allergies in kids... many doctors recommend delaying introduction of solids until 12 months of age).

    • Naomi Cook says

      Thanks for your comments! Spinach certainly is high in iron, the drawback with it is that it is very high in oxalates, which hinder the iron absorption (see point 3). But as I have said, there are many compounds present in iron rich food that can hinder absorption, it is easy to get quite bogged down with them. I would like to clarify something, research does not indicate that breastfeeding in addition to solids beyond 6 months poses a risk only that breastfeeding without introducing solids is the problem. I am still breastfeeding my 8 month old as well as giving her solid food and I also breastfed my three year old until she was 13 months. My research repeatedly stated that breastfeeding without solid food intake (after 6 months) posed a risk for iron deficiency because stores are highest in the first 6 months then start to decline (if you are interested have a look at references 8, 11 and 12). If you have read a study that disputes this, I'd like to have a look at it, as I have not heard this before. I would certainly not dispute that iron in breast milk is readily available, just that according to recent research it is not enough beyond that time. I would also like to say that I have not included any research that advocates routine iron supplementation, no, the focus in my research is mainly on prevention of iron deficiency through diet and preventing excessive milk consumption. I tried to demonstrate that through describing the supplements as "iron rich" rather than "iron supplements" but perhaps didn't make that clear enough, perhaps the word "supplement" is misleading. They certainly cannot be considered "iron supplements" in the true sense of the word as the iron content is very low (compared to the sky high dose in supplements for iron deficiency). I hope this makes sense and please let me know if I need to clarify anything else, Thanks!

      • Heather says

        Oh no, thanks for pointing out about the oxalates again. I did read that part and then forgot! We often put fresh orange juice in our smoothies so maybe the Vitamin C from that helps. I exclusively breastfeed my daughter for 12 months without introducing solids and she isn't iron deficient (this is just our personal experience of course, iron deficiency is very serious and I would not try to undermine it). I was iron deficient myself, but it was because I had undiagnosed celiac disease. Once diagnose, the iron deficiency went away. I know what it feels like as you mentioned (fatigue, dark circle under eyes etc!) Anyways, I did find this study you may want to read.. I did not read it all, however.. it's a bit long http://dianthus.co.uk/duration-of-exclusive-breastfeeding-and-risk-of-anaemia "In contrast, however, an Italian study found that exclusively breastfed infants had higher haemoglobin concentrations. So the evidence from that review that exclusive breastfeeding increases the risk of anaemia is very weak, particularly in developed countries. It is quite possible that the different nutritional statuses in developed and developing countries mean that trials in one setting are not generalisable to the other"

        • Heather says

          Oh I wanted to put out too (this may help someone, who knows) that I was iron deficient for *so long* and no matter what I did, I couldn't really get it under control. Meaning, if I went off any type of supplement I was on (floradix, for example) I would feel fatigued once more. It wasn't until I was diagnosed with celiac, and adjusted my diet - did the symptoms of anemia disappear and so did my need to take any type of iron supplementation. So I guess, sometime there is a root cause that has to be addressed.

        • Naomi Cook says

          I will try and have a look at some point thanks for that. Although I'd presently disagree with point that there is "weak" evidence available as I have looked at many of the clinical trials myself. I suppose the focus in modern science is "risk" ("risk society"). Knowing about "risks" and then personally deciding what to do with the knowledge of that "risk" (what works for you and your family). I'm glad to hear though that you had such a great breastfeeding relationship with your little one. I've been advised to wean my baby right now as she is reacting to food chemicals in my milk and needs to be on a strict elimination diet, which is sad for both of us :(

          • Heather says

            I think that the point is iron deficiency is possible, and your article helps to spread awareness so parents can look for the signs if they are present and hopefully avoid it with proper diet. My daughter has life-threatening allergies as well as mild ones and we were having a really hard time when she was younger because she had extreme ezcema and it seemed every food we gave her would irritate her skin. One person suggested weaning, but we found a great doctor to work with and weaning wasn't necessary after she had a blood test for allergies which revealed a tremendous amount of information and we were able to adjust my diet and hers for the better. Blood tests for allergies aren't always100% accurate, but luckily hers was right on and she quickly improved. She was 14 months though, not 8 months. Either way, good luck to you and your baby. I know how tough food allergies are!

        • Naomi Cook says

          Hi Heather, I thought I'd just get back to you on that study. The link you posted is to a discussion about introducing solids at FOUR months, not SIX as it is thought that may help prevent low iron levels through complimenting breast milk with iron rich food two months earlier than previous recommendations. The actual study you have quoted above is about exclusive breastfeeding for SIX months and then introducing solids. There is no mention of a study that recommends not introducing solids past six months. Even in the study you have quoted they have highlighted their own weaknesses. In addition, it is also worth remembering that iron can be low for quite some time before affecting haemoglobin, and that is the only yardstick they appear to have used; pushing the evidence even further in the direction of introducing solids at four months rather than six.

  2. Lindsey says

    Great post! We've been dealing with Iron in our family for quite awhile. When my son was 3 we took him to see a Doctor because he suffered from low energy, he was a terrible sleeper and often suffered from restless legs (his feet would be 'sliding off'). I hadread that all these things COULD be related to low Iron. We did some blood work and found out that his Iron was indeed VERY low. We used some supplements, changed his diet and whala! he's acting like a normal kid. Its wonderful. Thanks for all the additional food ideas, always looking for more ways to sneak in iron!

    • Naomi Cook says

      Fascinating. I can personally vouch for the fact that iron deficiency makes you feel pretty rough (and in pregnancy it exacerbated my 'twitchy legs'). Thanks for that information.

  4. Rachelle says

    1) I adore that you referenced. THANK YOU! 2) I often add just a little bit of baby cereal to lots of dishes (b/c it is rich in iron). For example, pancake batter ;-)

    • Naomi Cook says

      Great tip, I'll add it to pancakes tomorrow a.m!! Re references, yep, I wouldn't dare write anything without them, my word alone doesn't mean much, thanks for that!

  5. kellie says

    Thank you so much for your post Naomi, As a teaching naturopath and nutritionist I found your post to be wonderfully written, well researched and balanced. It was also very clearly structured and easy to understand. I am also a breastfeeding mother of a thirty one month old. I am always looking for more ideas to get iron rich foods into his diet. Thank you for giving me some extra ideas. Brilliant!!! kind regards Kellie

  6. Rose says

    I read all the above comments and want some input. My dd is 13 months. She has a iron count of 8, two months ago it was 8.6. She really does not eat at all. She still breastfeeds. I am going to put my foot down and try not to bf right before feeding her. In hopes hse sill eat more. Any tips? I will not stop bfing, until she is ready. I bf my son over 3 years. I am just stressed because it went down. I really feel like its because I was not pushing food. Thanks for listening, Rose

    • Naomi Cook says

      Hi Rose, I'm sorry to hear about your little one. Don't feel guilty, many people battle with borderline iron if they eat too little meat whereas others just flourish on a veggie diet lifelong without a single concern about their iron levels. We all absorb iron differently. My eight month old has just been diagnosed with low iron too, a result of my rock bottom iron levels in pregnancy. You sound like you have a plan, not breastfeeding until she has eaten something, reserving the feed for a 'dessert' of sorts. You could stick to this regime even for 'snacks' offering food before the breast. I presume the Doctor has recommended iron supplements. Getting iron up once it's that low is very hard and high doses are often prescribed. It would be extremely hard increase iron that low from diet alone, and the longer it takes the harder it is on your little one (and you!). He/she will have recommended the necessary dose. I hope that is helpful, please let me know if I can give you anymore information.

  7. Paris says

    Good job i am using this for my assignment but i was windering how do you prevent and manage it. i need as much help as possible!! Many thanks..

  8. Naomi Cook says

    Hi Paris, For prevention I'd focus on the section "Why toddlers are at Risk" (esp the section on excess milk consumption) since addressing those issues may count as prevention. As for management of an existing iron deficiency, a Doctor would most likely prescribe an iron supplement, relating the dose to the child's weight. These supplements are very high in iron and would be taken temporarily (as iron in high doses is toxic after all). Diagnosis would occur after a blood test. Ferro-Liquid is one pediatric iron supplement (ferrous sulfate). However as with most pediatric medicines it contains flavouring and preservatives. A compounding pharmacist can make up a preparation without these, for example, pure ferrous gluconate, and the mother can add syrup to make it more palatable. Another blood test after a few weeks of treatment may be necessary to re-assess iron levels and then cease supplementation. Good luck with the assignment!

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