Iron deficiency is a common reason doctors refer kids to see me in my practice. Many parents are surprised at just how common it really is in kids.
The high rate of iron deficiency in children is one of the biggest reasons that it is important for parents to understand the importance of iron-rich foods for kids.
In babies and toddlers, iron deficiency is usually due to a variety of reasons, but rapid growth and picky eating are two of the biggest factors.
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Iron needs for babies, toddlers & young kids
Iron is one of the top nutrients that growing babies and children need in their diet. It is a mineral found naturally in food and in foods that are fortified such as bread, pasta, cereal, oatmeal, and infant formulas.
Each age has its own iron requirements for varying reasons. In babies, rapid growth and brain development are two of the biggest factors for the large jump in iron needs around the 6-month mark.
As growth starts to slow in toddlerhood, iron requirements drop, until the next phase of growth that occurs around preschool age.
Iron needs by age
|Iron Need (7)
Iron deficiency in kids
Anemia related to iron is the most common childhood nutritional deficiency in the world. Therefore, iron is an essential nutrient to include in your child’s diet. (1)
A diet that is lacking iron can lead to iron deficiency or more severe iron deficiency anemia. (2) When the body doesn’t have a sufficient amount of iron, it cannot make a protein in the blood called hemoglobin. Hemoglobin is needed to transport oxygen throughout the body. Oxygen is needed in order for the body to function properly.
Children with untreated iron deficiency are at increased risk for problems with neurocognitive development and immune function later in life.
Therefore, preventing or reversing iron deficiency in a timely manner is critical. (3)
Causes of iron deficiency in kids
Iron deficiency anemia happens when there isn’t enough iron in the blood. This is generally due to the increased iron needs for growth in babies and young children. It is also related to the intake (or lack of intake) of iron-rich foods for kids.
Low iron intake from foods is one of the main reasons for iron deficiency in kids. This is even more common in picky eaters. If you struggle with a picky eater at home be sure to download my picky eating guide to help.
Other reasons for low iron include Malabsorption conditions such as celiac disease, Crohn’s and ulcerative colitis which interfere with the gut microbiome and damage the lining of the GI tract increase risk for iron deficiency. (4)
Following a vegan diet, that is not well planned also increases the risk of iron deficiency. Vegetarian diets pose a risk if iron-rich plant sources are not included.
- If you plan to raise your child on a vegetarian or vegan diet, it is critical that they have a good mix of plant-based iron sources paired with vitamin C each day. (Supplementation is also beneficial, especially for babies and toddlers.) However, a properly planned diet is important for all kids, vegan, vegetarian or not! Be sure to get enough of the iron-rich foods for kids.
How do I know if my child is iron deficient?
This is a tricky question. The reason this is tricky is that by the time you can see signs of iron deficiency, your child has likely been having low levels of iron for a while.
The body fights pretty hard to send iron where it is needed most, so it starts by pulling iron from its iron stores. Even though the brain needs iron for development (especially important in the first several years of life), the body knows that it needs iron for hemoglobin.
Hemoglobin is needed to transport oxygen. Your body can have normal a level of hemoglobin even when the iron is getting depleted in the body because hemoglobin is the last thing to decrease.
When you go to the pediatrician’s office and they prick your child’s finger, they are testing hemoglobin levels. You can actually have normal hemoglobin levels and still have low iron.
By the time the hemoglobin levels are low your child already has anemia.
If you do a full iron panel (which is not standard), you could see low iron levels before the hemoglobin is low via finger prick. The iron panel usually includes ferritin, iron and transferrin saturation, hemoglobin and hematocrit levels and total iron-binding capacity.
All of these change at different times in kids because many are affected by other things happening in the body (infection, inflammation, etc.) If a full iron panel is ordered ferritin is usually the first iron marker to be low when iron stores begin getting low. (5)
What are normal iron levels for babies and kids
When the pediatrician checks your child’s iron (via finger prick) in the office, they are looking at the hemoglobin levels. The “normal” range varies by age. If your child falls below the bottom end of the range, the doctor will usually recommend a full iron panel be done. This is recommended to rule out any other potential cause of the anemia other than iron.
Remember, if your child is below the normal range, they likely have already had low iron stores for some time before the low hemoglobin showed up. Start an iron supplement right away as iron-rich foods will not be enough to get the numbers up fast enough alone.
Signs of iron deficiency in kids
Most of the time, you won’t be able to see that your child is low in iron until they have an iron deficiency. Unfortunately, this also means that they likely had low iron for quite some time before signs appeared.
This is why I recommend ALL parents be proactive and really focus on iron-rich food sources for kids.
If you have a picky eater at home and you know they are consistently declining the iron-rich foods you offer, chat with their pediatrician about starting a multivitamin with iron.
Common signs of iron deficiency:
- Low hemoglobin (fingerstick is done at the doctor’s office)
- Not growing normally
- Motor and cognitive impairments
- Pica (a condition where they crave non-food items such as rocks, ice, clay, etc.)
- Thin sparse hair
- Redness, swelling cracking at corners of the mouth
- Sore swollen, red tongue
- Spoon shaped nails
If your child’s doctor identifies that your child has iron deficiency or low iron, supplementation is important. It is unlikely you will be able to get enough iron from the diet alone to raise the levels enough in a reasonable time frame. You do still want to begin incorporating iron-rich foods right away as well.
Other causes of anemia in kids
Although iron is the top cause of anemia, it is important to know that there are causes of anemia that are independent of iron intake, such as B12 deficiency. This isn’t super common in babies and children, but it can happen.
B12 deficiency is more common in babies and kids following a vegetarian or vegan diet which is naturally lower in B12. Mothers following a vegan diet who are breastfeeding should be supplementing with B12.
The primary reason the pediatrician may order a full blood panel after seeing a low hemoglobin level is to rule out B12 deficiency as the cause of the anemia. If iron supplementation is started but the cause the of the anemia was actually related to a B12 deficiency, the true issue could be hidden behind the extra iron and B12 deficiency would continue.
Thalassemia, which is an inherited blood disorder also leads to anemia, however, I won’t cover that in this post as this is not common.
Iron deficiency and picky eating
I recently had a mom in my office with a super “picky” little girl who was 3 years old. This little girl was loving her cow’s milk and fruit, but not into many other foods.
The mom was pretty stressed out about her weight (she was on the low end of the growth chart) so she was letting her drink a whole lot of milk so she wouldn’t lose weight. Her selective eating also meant she wasn’t eating many iron-rich foods.
It is not the first time I’ve seen this exact scenario, it’s actually very common among toddlers.
Right around the age of 1.5-2 yrs when growth starts to slow, picky eating tendencies start to take hold. If you are going through this phase with your own toddler, I recommend you read this post on what to do when your picky toddler won’t eat.
If you have a picky toddler, be sure to fully understand the foods that contain iron, so that you can identify which iron-rich foods they do eat. Continue to offer new foods, but try to include the iron-rich foods they like as well. If the picky eating is ongoing, or they consistently refuse most iron-rich food options, you should consider adding a multivitamin with an iron supplement. The supplement will help to fill in the gap and give you the peace of mind. I have a section below with supplement suggestions.
Milk intake and anemia in toddlers
Calcium, another mineral in the body, also competes with iron for absorption. Toddlers that are not eating enough iron-rich foods and drink large amounts of milk (which is high in calcium) have a higher risk of developing anemia.
I recommend 12-16 oz at most of milk/milk alternatives on a daily basis to my clients. No more than 24 oz/day.
I like to work with my clients to get their toddlers down to drinking around 4 oz. max of milk per serving. It’s also ideal to just offering milk with meals (around 12 oz. per day.)
Toddlers that consistently drink 24 oz. of milk or more per day are at higher risk of developing anemia. This is because of two major factors.
- The large intake of milk (that contains calcium) interferes with iron absorption
- When they are drinking that much milk they are getting full of milk and usually not eating enough of other foods, especially ones that contain iron.
Milk intake and anemia in babies
Milk and fortified milk alternatives are full of nutrients that benefit kids. But babies (under 12 mo.) should not drink cows milk/alternatives as a beverage.
The early introduction of cow’s milk as a beverage to babies (before one year) places your child at risk for iron deficiency.
This is because milk is a poor source of iron and it can fill up their small belly space meaning there is less room for iron-rich foods.
Infants less than one year should not drink any cows milk. Continue providing formula and/or breastmilk until at least 1 year. After one year, continue breastfeeding and you can also introduce milk/milk alternatives.
If you want to know more about the best milk/milk alternative options for your toddler or kids, check out this blog post: Milk vs. Milk Alternatives for Toddlers and Kids.
Why does baby formula contain cows milk?
Many people ask me why infant formulas contain milk if babies are not supposed to drink milk before one. Infant formulas that are cow’s milk-based account for about 80% of the infant formulas on the market.
When infant formula is cow’s milk-based it has been modified to be safe for infants.
The milk in the formula is heated to make the protein more accessible, and milk sugar (lactose) is added to make it more comparable to breastmilk. The fat is also modified to make it easier to digest.
Unless your child has an allergy or intolerance to cows milk/milk protein, milk-based infant formulas are perfectly safe to use and are usually iron-fortified.
Anemia in babies
Most infants get enough iron from their mother in utero to last until around the 4-6-month mark. However, the majority of iron transfer from mom to baby happens late in the third trimester. Many different factors can affect this transfer, which will be discussed later in the post.
Between 4 and 6 months of age iron stores become low/depleted and babies require iron from other sources in addition to breastmilk or formula.
Around 6 months, iron needs jump from 0.27 mg/day to 11 mg/day. (This is a pretty big increase!) The large increase in iron need is one of the main reasons for starting solids with iron-rich food sources.
If you are getting ready to start your baby on solid foods, or if you have already started and are unsure that you are meeting your baby’s key nutrient needs, check out my starting solids e-guide.
In this guide, I include all of the key nutrients your baby needs (including iron) and ways to provide them. I also include sample menus by age.
Iron in breastmilk
Exclusively breast-fed infants may be at higher risk for iron deficiency if iron-rich foods/supplementation does not occur. This is because human milk is low in iron. The percentage of iron in breast milk also changes over time.
Breastmilk is highest in iron during the first month of lactation and decreases each month going forward. However, iron needs are lower in infants from 0-6 months. Therefore, breast milk + iron stores from mom are usually enough to meet their iron needs until the 4-6 month mark.
The decreasing percentage of iron in breast milk is natural and normal, this means that the mother’s iron intake does not control the concentration of iron in breast milk. The body regulates iron on its own.
Changes in breastmilk iron levels
As the concentration of iron in breast milk decreases, the infant’s ability to absorb the iron remains high. Therefore, some exclusively breastfed infants can continue to get enough iron from their mother’s breast milk until they start solid foods.
Research has shown that the amount of iron absorbed from breast milk decreases as new foods are added to the infant’s diet, which places the exclusively breastfed infant at an increased risk of iron deficiency if iron-rich foods are not introduced appropriately.
When you start complementary foods, if you are also breastfeeding, you should offer food at a separate time from breastmilk. I generally recommend breastfeeding about 30-45 min before solid food feeds. (6)
Iron supplements for babies
The American Academy of Pediatrics recommends exclusively breastfed infants supplement with 1 mg/kg/day of iron starting at 4 months until iron-rich solids are started. (7)
This recommendation is often highly debated and therefore it is best to follow the advice of your personal pediatrician. Part of the reason this is highly debated is because some babies (those with excellent iron stores from transfer in utero) may not need an iron supplement.
What affects iron levels in babies?
Your baby’s iron stores and the transfer of iron from you to them is affected by a number of things during pregnancy and birth. The following may impact your baby’s iron levels:
- premature birth
- iron levels of mom during pregnancy
- the time before cord clamping
- genetics/family history of iron deficiency
- Certain conditions (such as malabsorptive diseases)
- 0ther un-explainable reasons
The variability of a baby’s iron stores is the primary reason universal supplementation recommendations were put into place.
That being said, I always recommend parents discuss with their child’s pediatrician so they can get a full account of your history and help you make the best decision for your baby on if a supplement is really needed based on your history.
Babies that are getting iron-fortified formula usually get enough iron from the formula and do not need additional supplementation unless recommended by their pediatrician for a specific reason.
In addition, babies started on solid foods earlier (closer to the 4-5 month range) that are getting iron-rich foods from the diet may not need a supplement.
If your baby is getting an iron supplement that was started around 4 months, once they are eating a good variety of iron-rich foods, no further iron supplementation is likely needed. Always chat with your doctor before starting/stopping a supplement.
Iron-fortified food for kids
Fortified food means that the food item did not naturally contain iron, but it was added to the product during processing.
In the 1900s, there were many vitamin and mineral deficiencies in children so the decision was made to fortify foods with key nutrients such as thiamin, niacin, riboflavin, iodine, vitamin D, and iron. These are all key nutrients needed for growth and development in children.
The high rate of vitamin and mineral deficiencies, including iron deficiency, is also one of the main reasons iron-fortified infant cereals were once strongly recommended as a first food for babies. (8)
Does my baby need cereal?
Recently, the use of fortified cereals in babies has declined and I have been getting more and more questions from parents about its safety.
The main reason people have this fear is that at one time, rice cereal was the recommended first food. Rice has been shown to retain high levels of arsenic due to the soil it is grown in. Because of this, many parents don’t include cereals at all. The popularity of baby-led weaning has also pushed parents away from fortified cereal.
I think it is important for parents to realize that rice cereal doesn’t have to be the first food. There are many other types fortified baby cereal available that are made of oats, which do not contain the levels of arsenic found in rice cereal.
Cereal, in general, doesn’t have to be the first food, especially if solids are introduced around 6 months when the baby is developmentally ready to start self-feeding. However, fortified cereal is a great addition to the baby’s diet. So it might be useful to have some on hand to use either in cereal form or to use in other products.
Fortified baby cereals can be used with both the traditional and baby-led weaning approaches or with the combination method, which I personally love.
Baby-led weaning pancake recipe
One of my favorite ways to use fortified baby cereal is for these baby pancakes which are perfect for baby-led weaning. They work well for toddlers and older kids too. (Confession, I eat them too!) If you don’t want to use fortified cereal, you can also use regular quick oats.
These pancakes are just 4 ingredients and are super quick and easy to make, which are perfect for busy mornings. Including fortified cereal in various ways in the diet of your baby and toddler is one way to add in plant-based iron.
Iron-rich foods for kids
There are two primary iron sources found in food, heme iron, which is in animal products such as meats/seafood and non-heme iron, which is found in plant-based iron sources.
Heme iron is more bioavailable, meaning it is more easily absorbed by the body alone than plant-based iron. About 30% of the heme iron you eat is absorbed.
Plant-based iron is absorbed around 2-10%, however, plant-based iron can be absorbed significantly better when it is paired with a vitamin C rich food sources (see examples further below.)
Heme iron-rich foods for kids
- Eggs (primarily in the yolk)
Non-heme iron-rich foods for kids
- Eggs (mostly the yolk)
- Sweet potato
- String Beans
- Dandelion Greens
- Collard Greens
- Prunes/prune juice
- Dried apricots
- Fortified bread
- Enriched pasta
- Fortified baby cereals
- Cream of wheat
- Bran cereal
- Oat cereal
- Rye bread
- Enriched Rice
- Legume pasta
- Beans (kidney, garbanzo, white beans)
Vitamin C rich food sources
- Citrus fruits (lemon, lime, grapefruit, oranges)
How is iron absorbed in the body
For those of you who like the details, you might be wondering how iron absorbed in the body. Iron is absorbed in the small intestine and travels in the blood by transferrin to be stored.
Adding vitamin C rich foods alongside iron-rich foods, help the body absorb iron more efficiently. If your child is struggling with anemia, it’s a good idea to add in a vitamin C rich food at each meal when possible.
Iron supplements for babies, toddlers, and kids
Iron is in supplements in a ferrous or ferric form such as ferrous sulfate, ferrous gluconate, ferrous fumarate, ferric sulfate, or ferric citrate. There is a lot of iron and multivitamin with iron supplements on the market. Look for supplements that contain the ferrous form of iron which is easier absorbed than the ferric form.
My personal favorite iron supplement is the Novaferrum brand supplements which come in several options based on age and dietary restriction (vegan, kosher, etc.) (I am not sponsored by this brand, I just have found that parents like it best.) Other common iron supplements that parents like are the poly vi sol with iron or the Zarbees brand, all of which are a liquid supplement, so they work well for babies and toddlers without teeth/good chewing skills.
I used the Novaferrum multivitamin with iron for a while with my daughter and she didn’t appear to have any stomach issues with it. Parents who start their kids on iron supplements report issues with stomach aches and constipation to me often, but most seem to tolerate the NovaFerrum pretty well.
Older children can also handle chewable multivitamins with iron or straight iron supplements as recommended by their pediatrician. I like the Animal Parade brand multivitamins, which has 10 mg iron/serving (2 chewable), they are also hypo-allergenic and vegetarian. (Again, I am not sponsored by this brand, this is just from experience from working with clients. I know other healthcare professionals who like this brand as well.)
Depending on your child’s iron needs they may be able to do just a multivitamin with iron instead of a straight iron supplement, which generally has a higher level of iron. Always talk with your child’s pediatrician before starting ANY supplement.
Iron and constipation in babies and children
Iron supplementation does increase the risk of constipation. If your child is suffering from constipation, there are natural remedies for constipation you can try. Watch your child’s behavior and bowel movements if iron supplements are used as each baby/child reacts differently.
There are a number of factors that affect your child’s iron levels. In babies, it is important to know the things that increase your baby’s risk of having lower iron levels. Be sure to discuss this with your child’s pediatrician.
Universal iron supplementation is recommended at 4 months, however, some babies may not actually need iron supplementation. If you are exclusively breastfeeding, low iron levels between the 4-6 month mark are more likely. Be sure to offer iron-rich foods right away when starting your baby on solids.
As your baby turns into a toddler and young child, be extra careful of how much milk or milk alternatives you are giving. Too much milk can increase anemia risk.
If you have a picky eater at home, be mindful of the iron-rich foods for kids. Do your best to offer them regularly for more opportunities to increase intake. A multivitamin with iron is also an option for picky eaters. This will give you peace of mind that they are getting enough iron while you work on getting them eating new food.
If you have a picky eater at home, be sure to download my free try new food guide!