The Importance of Iron
Karen H. Morin, DSN, RN
his month’s topic is in response
T 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 supple-
mentation, her request made me won-
der about the prevalence of iron defi-
ciency in the United States (and the
rest of the world), the impact of iron
deficiency on infant and toddler devel-
opment, who may be at risk, and
what recommendations are appropri-
ate to address the clinical problem not
only for breastfed infants but also for
formula-fed infants and toddlers.
Just How Common Is
Iron Deficiency Anemia?
This type of anemia is the most com-
mon 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 defi-
cient. The prevalence increased to 17%
for Mexican American toddlers and
12% for children from low-income
homes. Their more recent analysis indi-
cated little change in overall preva-
lence, although the prevalence de-
creased for toddlers from low-income
homes and for African American tod-
dlers. 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 de-
ficiency results in anemia, indicates
320 VOLUME 33 | NUMBER 5
that neurological development is im-
paired. 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 neurologi-
cal impairment in the presence of iron
deficiency without anemia is limited.
Who Is at Risk?
In addition to premature infants, in-
fants younger than 1 year of age are
most at risk, because iron supplies
with which they are born are ex-
hausted 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, re-
spectively. Recommendations are
more specific based on type of infant
feeding and gestational age.
Full-term infants of appropriate
gestational age who are breastfed re-
quire 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 re-
quirement 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 re-
quirement increases to 2 mg/kg/d for
low birthweight or premature breast-
fed infants. Moreover, supplementa-
tion 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 for-
mula should be used with premature
or full-term infants. Current formula
preparations, however, do not provide
sufficient iron to meet premature in-
fant needs. Thus, premature formula-
fed infants “could benefit from an ad-
ditional 1mg/kg/day, which can be ad-
ministered as either iron drops or in a
vitamin preparation with iron” (AAP,
2004, p. 308).
In addition to sharing all this infor-
mation with parents, nurses should re-
inforce 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 intro-
duce 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 popula-
tion of interest includes infants and
their parents! ✜
Karen H. Morin is a Professor and Di-
rector of Graduate Programs, Universi-
ty of Wisconsin–Milwaukee, and an
Editorial Board Member of MCN. She
can be reached via e-mail at
KHMorin@sbcglobal.net
References
American Academy of Pediatrics. (2004). Pedi-
atric nutrition handbook (5th Ed.). Elk Grove
Village, IL: Author.
Brotanek, J. M., Gosz, J., Weitzman, M., & Flo-
res, G. (2008). Secular trends in the preva-
lence of iron deficiency among US toddlers,
1976-2002. Archives of Pediatric Adolescent
Medicine, 162, 374-381.
Wierenga, F.T., Berger, J., Dijkhuizen, M. A., Hi-
dayat, A., Ninh, N. X., Utomo, B., et al.
(2007). Combined iron and zinc supplemen-
tation in infants improved iron and zinc sta-
tus, but interactions reduced efficacy in a
multicountry trial in Southeast Asia. The
Journal of Nutrition, 137, 466-471.
September/October 2008