Written by Dr Nické Theron, Pediatrician.
This is a topic that I have been avoiding for a while because there is so much conflicting advice and evidence available. I started giving our son iron supplementation from 6 months, but because it tasted horrible and stained all his clothes and he struggled with constipation, I stopped at around 10 months. After attending the European Academy of Pediatrics congress in September I was reminded about how important iron is for brain development, and I felt very guilty that I did not give Eran enough iron-supplements. But was it really necessary? When should babies and toddlers use iron-supplements and what sort of iron should they use? Read on to learn with me:
Iron is a vital mineral in our bodies. It is used in red-blood cells to carry oxygen and to help manage the storage and usage of oxygen in the muscles. Iron also plays a very important role in brain development in babies and toddlers, regulating the structure as well as the hormonal messengers of the brain. The immune system also needs iron to function well. Luckily the body regulates iron very closely, and as red blood cells break down it is recycled and used again. We do however loose a small amount of iron daily from our skins and gut, and during menstruation. If we do not take in enough iron to counter-act these losses, it leads to iron deficiency.
Adults need to absorb about 5% of their daily iron needs from food. Children need to absorb up to 30% due to their rapid growth and development. This already places them at a high risk for iron deficiency.
“Iron deficiency” occurs when there is not enough iron in the “stores” of the liver. (Mostly measured by doing a “Ferritin level” on a blood test). If there is no treatment it will progress to “Iron deficiency anaemia” where the iron-levels in the red blood cells are also dropping, leading to fewer and smaller red blood cells. (Measured by testing the “Hemoglobin level” or a “Full Blood Count”). It is mostly only when a child becomes pale and tired that the problem is picked up. However there is already a big effect on brain-development, behaviour and growth long before the “Iron deficiency anaemia” causes symptoms. Sadly iron deficiency is the most common nutrient deficiency in the world, and the effect it has on children’s behaviour and development is scary.
“As iron sharpens iron, so one person sharpens another”Proverbs 27:17
Children who have a high risk of iron deficiency are:
- Mother has an iron deficiency during pregnancy (the baby will still take the iron it needs, but there is not enough iron to totally fill all the stores)
- Mother has hypertension or diabetes mellitus during pregnancy (the iron in the mother’s body is not as easily available for baby / the baby has a higher need for iron)
- Premature babies (iron stores are filled during the last few months of pregnancy, so premature babies miss out on this. They also have a smaller blood volume and undergo many blood-tests while in NICU).
- Low-birth-weight babies (multiple reasons for high risk)
- Early cord clamping (allowing more blood to flow to the baby from the placenta increases the amount of iron they start out with)
- Insufficient dietary intake during early infancy
- Early introduction (<1 year) of unmodified cow’s milk or consuming large amounts of cow’s milk (>500ml) after 1year of age. (Early introduction may cause an increase of blood loss from the bowels as the bowels are not ready for the large proteins / via allergic reactions. Cow’s milk contains very little iron, thus the risk is high if your baby does not eat enough other iron-containing foods)
- Exclusive breastfeeding for longer than 6months (breastmilk has a very low iron content. See below. It is important to start iron-rich supplemental food from 6months).
- Picky-eaters, children with multiple food allergies, children following specific diets.
- Obese children
- Children with malnutrition, chronic diseases or bowel-diseases.
I would like to explain a little more about the iron-needs in babies. Term, healthy infants usually has enough iron in their bodies for the first 5-6months of life (they have a relatively high “hemoglobin” at birth and their stores are filled during the 3rd trimester). Their iron-needs are thus quite low during the first few months. Breastmilk contains very little iron (+- 0.3mg/L) but it is very easily absorbed (up to 50%). Formula milk is usually supplemented with up to 12mg/L iron, but it is not as available to be absorbed (4-6%).
After 6months of age the iron requirements increase rapidly, and thus breastmilk alone is not enough to sustain the iron-needs in babies. They need to take in extra iron in some form. Iron-rich foods and iron-fortified foods such as cereals has been shown to be more effective than medical supplements in the long term to sustain normal iron stores. (If your baby already has a deficiency it is easier to fill up the stores with medical supplements, see next article).
So how do you prevent iron-deficiency?
- The American Association of Pediatrics recommends that all healthy term babies who are exclusively breastfed should receive supplemental iron (1mg/kg/day) routinely from the age of 4months until they eat sufficient quantities of iron-rich food. (At least 2 meals per day containing iron rich food or iron-fortified food). The European society feels that there is no need for general iron supplementation in healthy babies and children as long as there are no other risk factors.
- Formula-fed babies should receive enough iron in the formula for the first 6months and thus do not need further supplementation.
- All premature babies should receive iron supplementation from the age of 2weeks until 1year (2-4mg/kg/day).
You can give the supplements as part of a multivitamin (eg Vidaylin with iron) or separately (eg Ferro-drops or Ferrimed). Seeing that there are some risks involved in using iron supplements in otherwise healthy children (some studies show that babies with normal iron stores that were supplemented with iron did not grow as well in length as those that were not supplemented) I think it is very important to discuss this topic with your pediatrician at the 6week check-up to make an informed decision with them after looking at all the risk factors for YOUR baby.
Iron deficiency has serious implications in your child’s development and should be carefully managed and monitored. In the next article I will discuss the effects of iron deficiency anemia and the treatment thereof.
- Lonnerdal B, Georgieff MK, Hernell O; “Developmental physiology of iron absorption, homeostasis and metabolism in the healthy term infant”; J Pediatr 2015 Oct; 167(4 0): S8-S14
- Baker RD, Greer FR, The Committee on Nutrition; “Diagnosis and Prevention of Iron Deficiency Anemia in Infants and Young Children (0-3years of age)”; American Academy of PediatricsClinical Report
- Friel J, Qasem W, Cai C; “Iron and the Breastfed infant”; Antioxidants (Basel). 2018 Apr; 7(4): 54
- ESPGHAN guidelines for Iron Requirements of Infants and Toddlers