Iron is a mineral essential to different bodily functions and processes. Most notably, it plays a central role in the production of hemoglobin, a protein found in red blood cells that carries oxygen from the lungs to the rest of the body [1]. Beyond its key role in oxygen transport, it’s also involved in energy production, immune system function, and cognitive development [2]. When a child's body does not have an adequate amount, it can lead to iron deficiency, which can make them feel tired and weak, affect their ability to learn and grow, and impair their immune system's ability to keep them healthy [2]. As such, iron is a very important mineral for children, and maintaining optimal levels is crucial for their growth and development.
Risk Factors
Iron deficiency in children can occur for several reasons, and in many cases is not due to a single factor. One of the primary contributors is a diet lacking in iron-rich foods, especially for children following a predominantly plant-based diet. Additionally, rapid growth during infancy and childhood increases the body’s demand for iron, which, if not met through diet or supplementation, can lead to deficiency. Pre-mature birth, low birth weight, or maternal iron deficiency can also put infants at risk due to low iron stores. Moreover, conditions like celiac disease—which can impair iron absorption—and chronic infections, or gastrointestinal disorders that cause blood loss are further risk factors [3]. Recognizing that iron deficiency in children is multifaceted is important in arriving at effective prevention and intervention strategies.
It's Challenging
As a parent or caregiver, you know your child better than anyone else does, and are the best person to evaluate if they are presenting with any signs or symptoms of iron deficiency. This can be challenging in certain cases because symptoms can be subtle and may overlap with other common childhood complaints. Children with mild iron deficiency may not display classic signs and some may have no symptoms at all [4]. Additionally, some children may not express their discomfort clearly, making it hard for parents and caregivers to recognize potential issues. Often, iron deficiency develops gradually and its impact on physical and cognitive development may not become apparent until it reaches a more advanced stage, which can delay diagnosis and treatment [5].
Despite these challenges, parents and caregivers need to become familiar with the signs and symptoms of iron deficiency in children.
Possible Signs & Symptoms [3]
tiredness
pale skin
dark circles under the eyes
restless legs
difficulty falling and/or staying asleep
concentration or attention issues
behaviour concerns
developmental delay
poor school performance
cognitive or intellectual impairment
irritability
depression
slow growth
poor appetite
breath-holding spells
a craving for chewing ice
If your child has one or more of these symptoms, or even does not but has one or more risk factors for iron deficiency, it may be worth speaking with their healthcare provider about evaluating their iron status. In any case, a blood test can be done to check iron levels, and if deficient, they can make appropriate recommendations.
Iron Up!
One strategy for boosting iron levels is to increase iron-rich foods in your child’s diet. Dietary iron exists in two district forms: heme iron and non-heme iron. Heme iron is found in animal-based foods such as red meat, poultry, and fish. It is called "heme" because it’s bound to a heme protein molecule, which gives it its reddish colour. Heme iron is well absorbed by the body, with absorption rates ranging from 15 to 35 percent, and its absorption is not impacted by other foods or factors. On the other hand, non-heme iron is present in plant-based foods such as beans, lentils, spinach, and fortified cereals. Unlike its counterpart, non-heme iron is not bound to a heme protein and is much less easily absorbed—with rates of approximately 2 to 5 percent—and its absorption is impacted by other foods and factors. To enhance the absorption of non-heme iron, consume these foods with sources of vitamin C such as citrus and bell peppers; stay away from dairy, tea, chocolate, and calcium supplements, as these can inhibit absorption [6].
Focusing on increasing iron-rich foods at every meal is an important strategy for both the prevention and treatment of iron deficiency in children.
Note: Regarding dairy consumption, it is recommended to delay the introduction of cow’s milk to an infant until 12 months of age, and afterwards, limit it to a maximum of 500 ml per day [1].
Health Canada’s age-dependent recommendations for daily iron intake [7]:
0.27 mg for 0–6 months
11 mg for 7–12 months
7 mg for 1–3 years
10 mg for 4–8 years
8 mg for 9–13 years
These requirements can be hard to meet on a daily basis as children would have to consume a significant amount of food to meet them.
The following are examples of good nutritional sources of iron and their iron content per serving [8]:
Heme Iron Foods
FOOD | IRON CONTENT (per 75g serving) |
Clams | 21mg |
Pork liver | 13mg |
Chicken liver | 9mg |
Oysters | 6mg |
Mussels | 5mg |
Beef liver | 5mg |
Beef | 2.5mg |
Sardines | 2mg |
Non-Heme Iron Foods
FOOD | SERVING SIZE | IRON CONTENT |
Pumpkin seeds (roasted) | 1/4 cup | 8.5 mg |
Organic whole grain iron- fortified infant cereal (dry) | 10 Tbsp | 6-7 mg |
Soybeans (boiled) | 3/4 cup | 6.5 mg |
Lentils (cooked) | 3/4 cup | 5 mg |
Red kidney beans (boiled) | 3/4 cup | 4 mg |
Blackstrap molasses | 1 Tbsp | 3.5 mg |
Spinach (cooked) | 1/2 cup | 3.5 mg |
Refried beans (canned) | 3/4 cup | 3 mg |
By reviewing these iron-rich foods and the serving size required to obtain a sufficient amount, it becomes evident that relying only on diet for improving iron levels in children can be difficult. This is particularly the case if a child is a "picky" eater and doesn’t favour iron-containing foods. For many children, iron supplementation—in addition to diet—is a better and more consistent strategy.
Supplementation
Your child’s healthcare provider may recommend an iron supplement, typically to be taken daily for three to four months before retesting iron levels. Several different forms of supplemental iron are available including ferrous fumarate, ferrous gluconate, ferrous sulphate, ferrous bis-glycinate, ferric pyrophosphate, polysaccharide iron complex, liposomal iron, and heme iron. Each form has particular benefits and disadvantages, and a supplement that may work for one child may not for another [9]. It’s important to discuss options with your child’s healthcare provider and together choose an appropriate form of iron to try.
The most important aspect of iron supplementation is consistency, and there are things that parents can prioritize to support its optimal absorption. If your child can tolerate taking the supplement on an empty stomach, this is the best way to avoid any inhibition of absorption caused by food. Taking the supplement just before bed is a great idea, but make sure your child brushes their teeth afterwards to pre- vent tooth discolouration. If taking the iron supplement on an empty stomach is not possible, or gives your child digestive discomfort, taking it with food is fine. It’s best, however, to time it at least two hours away from dairy products, tea, chocolate, medications, and other natural health products—particularly those containing calcium.
If your child’s iron levels do not sufficiently increase after three to four months of supplementation, they may need an adjustment in the dose or to try another form altogether. Remember that speaking with the prescribing doctor or naturopath for guidance is necessary when making these adjustments. You may also want to consider adding in a supplement that can enhance iron absorption such as lactoferrin [10], the probiotic Lactobacillus plantarum 299v [11], or vitamin C; however, as before, it is recommended to consult with a healthcare provider.
Although identifying and correcting iron deficiency in children comes with its challenges, it’s extremely important in supporting their physical and cognitive development. Testing and screening through bloodwork is the only way to properly evaluate iron levels in children. By being proactive and informed, you can ensure that your child grows up strong, healthy, and ready to embrace all the opportunities life has to offer.
**This article was originally published in EcoParent Magazine: www.ecoparent.ca.
References
Unger SL, Fenton TR, Jetty R, Critch JN, O’Connor DL. Iron requirements in the first 2 years of life. Canadian Paediatric Society. Feb 2, 2021. Accessed August 20, 2023. https://cps.ca/en/documents/position/iron-requirements
Hartfield D. Iron deficiency is a public health problem in Canadian infants and children. Paediatr Child Health. 2010;15(6):347-350.
Iron Deficiency – Diagnosis and Management. BC Guidelines. April 17, 2019. Accessed August 20, 2023. https://www2.gov.bc.ca/assets/gov/health/practitioner-pro/bc-guidelines/iron-deficiency.pdfÂ
Wang M. Iron deficiency and other types of anemia in infants and children. Am Fam Physician. 2016;93(4):270-278.
Saloojee H, Pettifor JM. Iron deficiency and impaired child development. BMJ. 2001;323(7326):1377-1378.
Appendix A: Dietary Aspects of Iron. BC Guidelines. Accessed August 20, 2023.  https://www2.gov.bc.ca/assets/gov/health/practitioner-pro/bc-guidelines/iron_deficiency_appendix_a.pdf
Dietary Reference Intakes. Health Canada. June 29, 2006. Accessed August 20, 2023. https://www.canada.ca/en/health-canada/services/food-nutrition/healthy-eating/dietary-reference-intakes/tables/reference-values-elements-dietary-reference-intakes-tables-2005.html
Iron in Foods. HealthLink BC. March 2022. Accessed August 20, 2023. https://www.healthlinkbc.ca/sites/default/files/documents/hfile68d_0.pdfÂ
Appendix A: Oral Iron Formulations and Adult Doses. BC Guidelines. June 15, 2010. Accessed August 20, 2023. https://www2.gov.bc.ca/assets/gov/health/practitioner-pro/bc-guidelines/iron-deficiency-appendix-a.pdf
Zhao X, Zhang X, Xu T, Luo J, Luo Y, An P. Comparative effects between oral lactoferrin and ferrous sulfate supplementation on iron-deficiency anemia: a comprehensive review and meta-analysis of clinical trials. Nutrients. 2022;14(3):543.
Vonderheid SC, Tussing-Humphreys L, Park C, et al. A systematic review and meta-analysis on the effects of probiotic species on iron absorption and iron status. Nutrients. 2019;11(12):2938.
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