1. Morin, Karen H. DSN, RN

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This month's topic is in response to an email by Sallie Porter, MS, RNC, CPNP, who asked about guidelines of supplementation when an infant or toddler is diagnosed with anemia. Although nurses know that breastfed infants need iron supplementation, her request made me wonder about the prevalence of iron deficiency in the United States (and the rest of the world), the impact of iron deficiency on infant and toddler development, who may be at risk, and what recommendations are appropriate to address the clinical problem not only for breastfed infants but also for formula-fed infants and toddlers.

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Just How Common Is Iron Deficiency Anemia?

This type of anemia is the most common nutritional deficiency in children in the United States (AAP, 2004; Brotanek, Gosz, Weistzman, & Flores, 2008). Brotanek et al. (2008), citing 2002 Centers for Disease Control and Prevention data, reported that 7% of children aged 1 to 2 years and from all socioeconomic levels were iron deficient. The prevalence increased to 17% for Mexican American toddlers and 12% for children from low-income homes. Their more recent analysis indicated little change in overall prevalence, although the prevalence decreased for toddlers from low-income homes and for African American toddlers. From a global perspective, as many as 50% of infants and toddlers residing in developing countries can be anemic by the age of 1 year (Wierenga et al., 2007).


What Impact Does Iron Deficiency Have on Infant and Toddler Development?

The evidence, strongest when iron deficiency results in anemia, indicates that neurological development is impaired. The effect of impairment is demonstrable through learning and socioemotional difficulties and lower scores on motor development and mental tests. Moreover, the effect seems to be long lasting (Brotanek et al., 2008). The evidence for neurological impairment in the presence of iron deficiency without anemia is limited.


Who Is at Risk?

In addition to premature infants, infants younger than 1 year of age are most at risk, because iron supplies with which they are born are exhausted during this period of rapid growth. Recent data indicate that Hispanic toddlers, toddlers who are younger (1 versus 2 years of age), and toddlers who are overweight have a greater risk of iron deficiency (Brotanek et al., 2008).


What Guidelines Are Available?

The recommended Dietary Reference Intakes for infants younger than 6 months, infants between 1 and 12 months, and toddlers between 1 and 2 years are 0.27, 11, and 7 mg/d, respectively. Recommendations are more specific based on type of infant feeding and gestational age.


Full-term infants of appropriate gestational age who are breastfed require supplementation of about 1 mg/kg/d, beginning when the infant is at least 4 months old and before 6 months (AAP, 2004). Ideally, this requirement is met by consumption of complementary food. For example, two servings of iron-fortified cereal meet the requirement. When oral iron supplementation (elemental iron) is needed, dosage is based on the 1 mg/kg/d requirement. The requirement increases to 2 mg/kg/d for low birthweight or premature breastfed infants. Moreover, supplementation occurs when the infant is 1 month of age and continues until the infant is 12 months old (AAP, 2004).


If formula is the method of choice for infant feeding, iron-fortified formula should be used with premature or full-term infants. Current formula preparations, however, do not provide sufficient iron to meet premature infant needs. Thus, premature formula-fed infants "could benefit from an additional 1mg/kg/day, which can be administered as either iron drops or in a vitamin preparation with iron" (AAP, 2004, p. 308).


In addition to sharing all this information with parents, nurses should reinforce that cow's milk should not be used for the first year of life. Should a parent wish to offer an infant a bottle before the infant's first birthday, then iron-fortified formula should be used. Parents can be encouraged to introduce foods high in iron (such as beef, poultry, iron-fortified cereals and breads) when they begin to introduce solids to their infant. Reminding them of these simple strategies is all in a day's work for nurses whose population of interest includes infants and their parents!!




American Academy of Pediatrics. (2004). Pediatric nutrition handbook (5th Ed.). Elk Grove Village, IL: Author. [Context Link]


Brotanek, J. M., Gosz, J., Weitzman, M., & Flores, G. (2008). Secular trends in the prevalence of iron deficiency among US toddlers, 1976-2002. Archives of Pediatric Adolescent Medicine, 162, 374-381. [Context Link]


Wierenga, F. T., Berger, J., Dijkhuizen, M. A., Hidayat, A., Ninh, N. X., Utomo, B., et al. (2007). Combined iron and zinc supplementation in infants improved iron and zinc status, but interactions reduced efficacy in a multicountry trial in Southeast Asia. The Journal of Nutrition, 137, 466-471. [Context Link]