Iron Deficiency in Toddlers: What Parents Must Know

When I think of iron, I think of that amazing scene from the movie “Oliver Twist” where the children all sing “Food, glorious food”. And that is just it! A condition that is affecting about 40% of children between the ages of 6 months and 5 years is iron deficiency. The major cause for this iron deficiency is due to an inadequate diet. Why is this important?

According to American Academy of Paediatrics (AAP)

“Iron is the most common single-nutrient deficiency among children in developing countries and is a common cause of anaemia in industrialised nations. Evidence shows that iron deficiency and iron deficiency anaemia during infancy and childhood may have long-lasting detrimental effects on neurodevelopment that may not be reversible.”

The AAP goes on to say that all children should have an iron test when they turn one year of age. 

Why is iron so important?

This amazing nutrient has a very big responsibility. It helps move oxygen from the lungs to the rest of the body. We all know what happens when there is a lack of oxygen! The body’s organs and tissues are not able to function properly and we certainly don’t want this in a young, developing body.

How would I know if my child was lacking iron?

If your child is a picky eater, gets recurrent infections or often complains of being tired, it is likely that this little person is lacking iron. Another strong tell-tale sign is a child that eats odd things like ice, soil or paper. This is known as PICA.

The only way to say for sure that there is an iron deficiency is to do a blood test. I know that this is not the answer that parents want to hear but given the vital role that iron plays in your child’s development, it is really important that you know what the levels are so that appropriate action can be taken.

The common signs of an iron deficiency include:

• Pale skin due to lower red cells, in the blood stream.
• Irritability. Low oxygen levels to the brain can impact how the brain functions and this leads to behavioural issues.
• Feeling tired or weak. This is because the body’s tissue isn’t getting enough oxygen to produce energy.
• Recurrent infections- especially respiratory and gastroenteritis because the child’s immunity is affected.
• Having headaches or dizziness. This is again due to lowered levels of oxygen reaching the brain.

In the case of infants, who can’t tell you how they are feeling, the little one may experience:

• Poor sleep patterns. A lack of iron affects oxygen levels to the brain, which in turn results in changes to the sleep wake cycles of a baby.
• Breath holding attacks. Low levels of oxygen in the blood stream can affect the functioning of the automatic nervous system that regulates breathing and heart rate.
• Developmental delays. When iron is deficient certain brain activities are affected and this may lead to cognitive, motor and social-emotional problems.
• Regressions in development. This again is because oxygen levels to the brain are affecting the functioning and the baby may lose some of the milestones he or she already achieved.

Why does a child become iron deficient?

I think it is safe to say that the most common cause of iron deficiency in children, is simply that they are not getting enough of it in their diets. For me this is a good thing because it means we can take steps to correct it. There are other causes like intestinal disorders and bleeding, but this is rare.

Let’s break it down:

In the newborn phase:

• A premature baby is usually born with lower iron stores than a full-term baby simply because it spent less time in the womb and wasn’t given as much time to gain stores from mom. Premature babies also need iron to support their rapid growth and they may also lose blood from procedures done while in the neonatal unit. These babies require supplementation.
• If a baby’s cord is clamped immediately then baby will not get as much iron from mom as he or she would have got if cord clamping was delayed. If the cord is clamped 1 to 3 minutes after birth, then the risk of iron deficiency is reduced.
• Breastfed babies absorb iron from breastmilk more easily than babies who are formula fed. It is very important that formula fed babies receive a formula that is fortified with iron.
• Moms who follow a vegan diet must make sure that they are on a good iron supplement during pregnancy to ensure that baby gets the iron it needs for the first 6 months of life.
• A baby has adequate iron stores from Mom, up until about 6 months of age. After this the stores become depleted and the child has to get iron from his or her own food. You can see why it is important to get solids going no later than 6 months.
• Babies who are given cow’s milk in the first year of life may develop iron deficiency. This is because other nutrients like the calcium in cow’s milk slows down iron absorption.

Between the ages of 9 months and 24 months:

• Children are growing rapidly and the demand for iron may exceed the amount of iron in the food they are eating.
• Children who prefer milk to food are at a high risk for becoming iron deficient. Parents often comment that they give the milk to make sure the child at least has something. Milk will cause the child to eat less and does not provide the iron needed in this phase. It also contains calcium which slows down iron absorption.
• Children in this age group are known for their food battles so it isn’t easy. Children who refuse to eat meat and are picky about vegetables are going to present with iron deficiencies.
• Children who follow a vegetarian diet that is not well controlled are also at a high risk for iron deficiency. I always recommend that these children are followed up by a dietician to ensure that a deficiency doesn’t occur.

What can be done to prevent or treat iron deficiency?

Medical intervention

If a child presents to a doctor with any symptoms of iron deficiency, then I would definitely suggest an iron study be done. This does involve a blood test. The doctor may decide to prescribe iron, if the levels are low. I know that parents dread blood tests, but the long-term effects of iron deficiency need to be taken into account. Iron supplementation may cause your baby to have a black stool for a few days, cramps, constipation or diarrhoea. These symptoms will pass when your child adjusts to the supplement. There are newer supplements that don’t cause as many side effects, so chat to your doctor about the options.

Children who have had gut problems may need other treatment first before iron is given. H-pylori is a bacterium that affects the tummy. A stool test would need to be done to test for this. H-pylori is treated with an antibiotic.

Parent intervention

 I really get excited when there are things that parents can do in the case of a medical condition. Iron deficiency prevention and treatment is one of these conditions.

You remember Oliver Twists “food, glorious food”? Well, this is your best weapon against iron deficiency. Let me give you some suggestions:

• Try the fun “100 foods by the time I am one” challenge. You can get this off Google or an app. Giving children such a wide variety of food by the time they are 1 year old will ensure that nutritional requirements are met. This challenge suggests things like bell peppers, cannellini beans, falafel, kiwi, lemons, mint, quinoa and so on until you have gone through the whole alphabet and 100 foods!
• Limit the amount of cow’s milk your child has, to less than 500mls per day.
• Vitamin C increases the body’s ability to absorb iron. A squeeze of lemon over food not only brings out the flavour, but aids in iron absorption.
• There are two kinds of food which contain iron. Heme iron comes from animal-based foods like meat, chicken, turkey or seafood. The body can absorb 20% of the iron contained in these foods. The good thing is that the amount of iron is not affected by how you cook this food. You can use it in your child’s favourite dish. Non-heme iron is found in plant-based food like nuts, whole grains, beans, broccoli, sweet potatoes and strawberries. Only about 5% of this iron is absorbed and it is dependent on how the food is prepared. This is why a vegan or vegetarian diet is trickier. Way more food needs to be eaten to get the same amount of iron from non-heme foods and it has to be properly prepared.
• Picky eaters pose a whole new problem when trying to get a child’s iron stores up. It is tough but not impossible. Work with what your child will eat while you slowly tempt him or her with new foods. There are such amazing recipes available for this. An example may be a child who only likes starchy food. I found an amazing recipe for muffins made from white beans. It doesn’t sound good, but believe me they are delicious and you would never know that there were beans in it at all. So cool! https://www.theleangreenbean.com/white-bean-muffins/

If you are looking for ideas, then you have a world of ideas at your fingertips on the web. Remember, adding foods that contain Vitamin C will improve iron absorption from the meal. Here are a few suggestions:

Breakfast:

• Toast with peanut butter and a slice of kiwi fruit
• Jungle oats with strawberries
• Waffles with peanut butter and mango
• Flax seed muffin with blueberries
• French toast with a choice of fruit

Lunch:

• Spaghetti with tomato sauce
• Cheese and tomato sandwich with an apricot
• Tuna salad
• Fish cakes with peas and a squeeze of lemon. See BabyYumYum’s Tuna Fishcakes: A Crispy and Flavourful Classic recipe. 

Dinner

• Mince, quinoa and broccoli
• Chicken with whole baby potatoes and crunchy carrots (some squeezed orange as a dressing is delicious and full of Vitamin C)
• Fish with mash potatoes and shredded spinach or peas

Conclusion

All parents want to ensure that their child is growing normally and developing the way he or she should. Iron is the key nutrient for this. I know from my own children that picky eaters often miss out on whole food groups like meat, legumes and green vegetables. This is usually because they are sensory defensive and unwilling to try a variety of foods. The best way to get enough iron in the diet is by providing variety, but if your child won’t eat it, stick to what they will eat like fortified cereals, breads and pasta. Add products that contain vitamin C to these dishes like tomato sauce (homemade if possible) and fruit. A squeeze of lemon goes unnoticed by those little eyes, but in the diet, helps with iron absorption. Prevention is always better than cure so work hard on food variety in the first year of life. It can be fun and is absolutely critical to your toddler’s wellbeing.

Sources:

• PMC: Iron Deficiency Anemia in Infancy, Childhood, and Adolescence
• AAP Reports on Diagnosis and Prevention of Iron Deficiency Anemia
• PUBMED: Childhood iron deficiency anemia leads to recurrent respiratory tract infections and gastroenteritis
• HEALTHY CHILDREN: Anemia in Children and Teens: Parent FAQs
• MAYOCLINIC: Iron deficiency in children: Prevention tips for parents
• REDCROSS: Iron Rich Foods