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:

  1. Iron deficiency anemia (small, pale red blood cells)
  2. 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

  1. 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.
  2. 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.
  3. 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.
  4. 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.