Iron deficiency in babies and toddlers

Why iron runs low at about 6 months

Iron helps red blood cells carry oxygen around the body, and it’s needed for growth and development. Babies need a lot of it because they grow so fast in the first year (AAP).

Healthy full-term babies are born with iron stores that usually last for about the first 4 to 6 months (NIH). After that, breast milk alone doesn’t supply enough, and the NIH says full-term babies could become iron deficient by 6 to 9 months unless they eat iron-rich solid foods or drink iron-fortified formula.

How much iron children need (NIH):

• 7–12 months: 11 mg a day
• 1–3 years: 7 mg a day

When iron stays low for a while, iron deficiency can turn into iron deficiency anemia, where the body can’t make enough healthy red blood cells (AAP). The AAP says at least 15% of US toddlers show signs of iron deficiency. Low iron in early childhood has been linked to delays in development, learning and attention (AAP, CDC), so it’s worth preventing.

Signs of low iron

Early on, there are often no obvious signs: the body uses up its stored iron first (NIH). That’s why screening matters (see below). As iron drops further, the AAP lists:

• pale, yellowish or ashy skin
• pale cheeks, lips, nail beds and inner eyelids
• low or irritable mood
• mild muscle weakness
• tiredness, or needing more naps
• craving or chewing non-food items like ice, dirt or paper (pica)

If you notice any of these, talk to your pediatrician, GP or health visitor. They can check with a simple blood test. Low iron is usually easy to treat (AAP).

Who is at higher risk

• Babies born early or with a low birth weight. Their iron stores are lower from birth (NIH), and the AAP says they can benefit from iron supplements starting about 2 weeks after birth.
• Babies who are mostly breastfed after about 6 months, especially if iron-rich foods are slow to get going. The AAP recommends iron drops from 4 months for babies who are partly or fully breastfed, until iron-containing foods are introduced (a newer AAP page says around 6 months), and the CDC says to ask your doctor whether your baby needs them.
• Babies whose mothers had diabetes in pregnancy, or who were small for their gestational age (AAP).
• Babies given cow’s milk as a drink before 12 months, and toddlers who drink a lot of milk (see below).
• Children who don’t eat meat, poultry or fish. The NIH says vegetarians need almost twice as much iron, because plant iron is harder to absorb. See vegetarian and vegan babies.
• Children with conditions that cause blood loss or poor absorption, such as inflammatory bowel disease or bleeding disorders (AAP), or celiac disease.

Cow’s milk: too early, or too much

• Before 12 months, don’t give cow’s milk as a drink. The AAP says it can cause blood loss in the stool and lowers iron absorption at this age. In the UK, the NHS says cow’s milk can be used in cooking or mixed into food from around 6 months. The CDC says not to give cow’s milk before 12 months. If you follow US advice, use breast milk or formula in your baby’s food instead.
• After 12 months, the AAP says to limit milk to no more than 24 oz (710 ml) a day. Milk is low in iron and fills toddlers up, so they eat less iron-rich food. See cow’s milk at 12 months for how much to aim for.

Screening for iron deficiency

In the US, one AAP page recommends that all babies be screened for iron deficiency and anemia at 12 months, and the CDC says your baby’s doctor will likely test for anemia at around 12 months. The AAP’s newer guidance gives different timing by feeding: about 9 to 12 months for babies who mostly have breast milk, and 15 to 18 months for babies who mostly have infant formula, which is usually fortified with iron. Ask your pediatrician when they plan to check your child.

Iron-rich foods

Offer an iron-rich food at most meals from the start of solids. The CDC explains that heme iron, in meat, fish and poultry, is absorbed more easily, while non-heme iron, in plants and fortified foods, is absorbed less well.

Best heme sources: beef and lamb (AAP, CDC). Cook meat until very tender, then mince, shred or mash it.

Best non-heme sources: iron-fortified infant cereal, lentils, chickpeas, tofu, tempeh and cooked spinach (AAP, CDC). Plain enriched English muffins also count: about 4 mg of iron per 100 g, or about 1 mg in a 25 g piece (USDA). Toast them lightly, cut them into narrow strips, and offer them once wheat has been introduced on its own.

Smaller amounts: chicken, dark-meat turkey, sardines, eggs, quinoa, kale and broccoli also give some iron (AAP), and the iron in poultry and fish is the well-absorbed heme kind. They’re good foods, but don’t rely on them alone. Remove all bones from fish.

Help iron absorb: pair plant iron with a food rich in vitamin C, like soft-cooked broccoli, tomatoes, berries (squashed flat or cut small), papaya or sweet potato (CDC). Eating meat, poultry or fish at the same meal also helps (NIH).

For serving ideas by age, see iron-rich first foods.

Treatment: follow your doctor’s plan

If your child is diagnosed with low iron, the doctor will usually prescribe a daily iron supplement by mouth, plus advice on iron-rich foods (AAP). Give the exact dose prescribed, for as long as prescribed. Iron supplements can cause tummy upset, constipation or darker poop (NHS).

Don’t give iron drops or iron-containing vitamins without medical advice. The symptoms of low iron overlap with many other things, and too much iron is harmful. The NIH upper limit for babies and children up to 13 years is 40 mg a day from all sources, unless a doctor prescribes more for a while.

Iron overdose is an emergency

The NIH says accidental overdose of iron-containing products is a leading cause of fatal poisoning in children under 6. A severe overdose can happen if a child swallows adult multivitamins, such as prenatal vitamins, or iron tablets, which can look like candy (NIH MedlinePlus). The NHS warns that an iron overdose in a young child can be fatal.

• Keep all iron products, including your own, in their child-resistant packaging and locked away or out of reach.
• Signs can include vomiting (sometimes with blood), diarrhea, black or bloody poop, drowsiness and pale skin. Symptoms can seem to go away for a few hours, then come back a day or more later (NIH MedlinePlus). Don’t wait for symptoms.

If your child may have swallowed iron tablets or adult vitamins: call Poison Help at 1-800-222-1222 right away, even if they seem fine. If they’re unconscious, having a seizure, struggling to breathe or vomiting blood, call 911.call 999 or go to A&E (NHS). Don’t drive yourself: ask someone else to drive, or call 999 for an ambulance.call your local emergency number (such as 112 in Europe or 000 in Australia) or your local poison information center right away. Don’t try to make your child sick (NHS). Take the packaging with you, and note how many may have been swallowed and when.

Where US and UK advice differs

• Screening. The AAP recommends checking babies for iron deficiency: one AAP page says at 12 months for all babies, and a newer one says about 9 to 12 months for mostly breastfed babies and 15 to 18 months for mostly formula-fed babies. The NHS doesn’t describe a routine iron check for babies: if you’re worried, ask your GP or health visitor, who can arrange a blood test.
• Iron drops for breastfed babies. In the US, the AAP recommends iron drops from 4 months for partly or fully breastfed babies, until iron-containing foods are introduced, on your pediatrician’s advice. In the UK, the NHS doesn’t recommend routine iron drops: the routine vitamin drops it recommends contain vitamins A, C and D only, not iron. See vitamins for babies.
• Emergency routing. In the US, Poison Help (1-800-222-1222) gives free expert advice 24 hours a day and will tell you what to do. In the UK, the NHS says to call 999 or go to A&E if a child may have swallowed something harmful, and NHS 111 if you’re not sure.