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How can you tell if your kids need iron? How do you supplement? Is it safe? Is it necessary? Can you fix iron deficiency anemia with just food?

In my pediatric nutrition practice, I often find kids need iron that they aren’t getting, and no one has noticed. I’m often in the position of suggesting iron screening. I meet many kids who show signs of anemia, pre-anemia, or marginal iron status, but haven’t been properly screened. Iron repeatedly pops up as problematic for many US children, based on government survey data collection that began in the early 1960s. Anywhere from 5% to 15% of kids in the US are in poor iron status. Being overweight appears to double the risk for kids, of having low iron. There are racial and ethnic disparities too, with non-white children possibly more likely to have low iron status. Kids need iron, most often, if they …

  • Were born prematurely, or had low birth weight
  • Are ages 1 to 5 and drink more than 24 ounces of cow’s milk, goat’s milk or soy milk a day
  • Have chronic infections, picky eating, or restricted diets that omit iron rich foods
  • Have frequent diarrhea/loose stool
  • Have been exposed to lead
  • Are overweight or obese.

How iron works in the body is a complex topic. It has many jobs besides helping blood carry oxygen to tissues. Weak iron status will trigger cognitive and behavior problems in children. In many cases I’ve encountered, hyperactivity and inattention  have been an indication that kids need iron. Low iron can have lasting, possibly irreversible, negative impacts on IQ, if it has been present long enough or early enough. Interestingly, iron is especially key for math learning – so if math tasks stand out as problematic for your child, consider iron screening. Iron is critical for normal immune function and neurotransmitter balance too. So if depression, anxiety, or insomnia are in the mix, once again, iron may be part of the problem.

As necessary as iron is, it is also toxic. Our bodies have ingenious ways to shuttle iron around safely, so it doesn’t damage tissues or overload pathways where it isn’t needed. Too much of it can be lethal for anyone – not just children, though children are more vulnerable more quickly, by virtue of their smaller body weight. If you are supplementing iron, do it with professional oversight, so you can be sure your child isn’t getting too much.

If you aren’t sure if your kids need iron or what to do, ask your pediatrician for deeper screening than the usual single drop of blood for a hemoglobin level. This will require a blood draw, but it can be worth the trouble to safely correct iron status if a supplement is needed.

Even if you learn that a high dose iron supplement is not needed, this is good information that guides you in safely replenishing your child’s iron status with food, iron fish, or lower dose iron supplements. Mild to moderate iron deficiency may show no obvious signs or symptoms, but can be debilitating nevertheless – and this is where a blood test can be useful. Ask for these tests:

  • ferritin
  • transferrin
  • serum iron
  • total iron binding capacity
  • percent iron saturation
  • total unsaturated iron binding capacity
  • complete blood count
  • hemoglobin
  • hematocrit

Just checking hemoglobin (Hgb) and hematocrit (Hct) – usually checked with a quick finger-prick and single drop of blood at about age one year – is not quite enough to truly identify whether or not kids need iron. Checking just Hgb and Hct can be too little, too late, when it comes to screening iron status. This is because both these lab values will stay in normal ranges even after kids need iron supplementation. Because Hgb is so critical for oxygen transport to the brain, it is the last thing the body will allow to fall out of range. If your child’s Hgb value is below range, s/he probably has needed iron and/or more dietary protein for a long time.

At the least, ask your doctor to include a ferritin level test in any iron screening. Though reference ranges drop as low as 6 or 10 nanograms per milliliter for ferritin, children function better when ferritin is in the 30-60 range, in my experience clinically. If below this level, depending on other findings, kids may need iron, better protein, or various supplement strategies to improve ferritin, hemoglobin, serum iron, and overall functioning.

shiners on child low iron

These signs may stand out when kids need iron – especially if they are not in full blown iron deficiency anemia with low hemoglobin, but are entering a state of pre-anemia, with iron stores dropping:

  • Dark circles under eyes
  • Pale countenance
  • Broken, restless sleep
  • Irritability, mood lability
  • Depression, anxiety
  • Frequent infections, colds, illnesses
  • Inattention, hyperactivity

At this point, your child may have pre-anemia. The body is not yet fully depleted for iron, but ferritin may be dwindling. Ferritin is a storage molecule for iron. Once it is low, there is little cushion for the body to sustain demands for iron – things like infections, colds, busy learning activities, or normal sleep rhythms, not to mention physical exertion. You can consider foods that are iron rich as well as gentle herbal supplements (be sure to ask your doctor for guidance) or iron supplements, in the 5-10 mg range daily.

Once a child is anemic, things change. At this point, the body is truly depleted for iron. Your child may exhibit:

  • breathlessness, easily fatigued
  • sleepy during the day
  • unable to complete tasks
  • physical weakness
  • dizziness
  • cold hands and feet
  • irregular heart beat
  • anxiety, apprehension
  • chest pain
  • veins visible through pale skin
  • nose bleeds
  • heavier, more painful menses

The detailed iron study lab tests will guide the replenishment strategy. Your child may need high dose iron supplements. Be sure to follow your doctor’s instructions when using iron supplements. Once the body is anemic, iron can take months to restore. Your doctor may repeat blood work after some time on an iron supplement, to monitor progress. Don’t use doses this high on your own – get guidance.

Typically, pediatricians prescribe a form of iron called ferrous sulfate. Many kids don’t tolerate this well. Ferrous sulfate can cause stomachaches, constipation, headaches, backaches, and poor appetite. Some children also have dramatic spikes in disruptive behaviors when they take the iron they need. Other more tolerable forms are available, such as ferrous bis-glycinate, food based supplements, or iron rich herbal liquids. Liquids, chewables, and tablets are available.

Keep up any iron rich foods that your child can tolerate: Eggs, lentils, pumpkin seeds, red meats, dark leafy greens, sesame tahini, chick peas, hummus, Brussels sprouts, raisins, dried peaches, potatoes with skin on, arugula, sunflower seeds or sunflower butter. If your child doesn’t like these foods, you may have some work to do correcting gut microflora. Doing so usually broadens appetite.

If your child reacts badly to an iron supplement, especially with behavior spikes, this is another indication that you may need to balance gut microflora before supplementing. Microbes love iron, and giving it orally in high doses can essentially “fertilize” these microbes in the gut or body. This can manifest behaviorally. Investigate if there are active gut infections for Candida, Klebsiella, or other disruptive species. Clear them out with medications or herbs, and proceed with iron restoration from there. This can work best in some cases.

Another caveat is chronic inflammatory conditions. Inflammation in the body can shift iron findings on lab tests. Kids with asthma, rheumatoid arthritis, cancer, chronic illness, Crohns disease, or allergies may show a shift on blood work that makes iron status look weaker. Serum iron may be low while iron stores (ferritin) are high. If your child has a chronic condition and you are concerned about anemia, ask your doctor to refer you to a specialist who can help, as this may be beyond the scope of practice for your pediatrician.

Kids need iron more often than you might think! It’s a deal breaker nutrient that can trigger big shifts for the better, once it’s balanced in your child’s brain and body. If you have more questions about how to assess iron or what to do, comment below and thanks for stopping by!

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