How can you tell if your child needs extra iron? How do you supplement? Is it safe? Is it necessary? Can you do it with just food?

I’m asked these questions a lot, and I’m often in the position of suggesting iron screening, for kids who show signs of anemia, pre-anemia, or marginal iron status. 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.

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. It’s one of the first nutrition pieces to screen when kids have hyperactivity and inattention. Low iron can have lasting, possibly irreversible, negative impacts on IQ, if it has been present long 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. So, if you are supplementing iron, do it with professional oversight, so you can be sure your child isn’t getting too much. If you are uncertain, ask your pediatrician for screening. This will require a blood test, but it is well worth the trouble, to safely correct iron status if a supplement is needed. Even if you learn that it is not needed, this is good information that can keep you safely replenishing your child with food. Mild to moderate iron deficiency may show no obvious signs or symptoms, and this is where a blood test can be useful. A thorough iron assessment includes these lab 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), which can be checked with a quick finger-prick and single drop of blood, is no longer regarded as sufficient to assess iron status. Once those two tests drop below the reference range, it’s likely that low iron has been a problem already, for a long time. In other words, checking just Hgb and Hct is a case of too little, too late, when it comes to screening iron status. At a minimum, your doctor should 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 it is at 30 or 40. In my own practice, any child with a ferritin below 30 will receive nutrition support to improve iron status, if they exhibit any of the signs below. Depending on other findings, this may be from food, from herbs, or from iron pills – but in any case, all is carefully monitored.

Signs of weak iron status include…

• 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 toward the 20s or teens. 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

Blood work guides the replenishment strategy. Your child may need high dose iron, at levels in this table below, for some time:

Once the body is anemic, iron can take months to restore. Your doctor may (should) repeat blood work after a few weeks 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 iron rich foods of course too – 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.

Iron is a deal breaker nutrient – like any other! Nutrients are nutrients because research has shown them to be essential. Without them or with weakened status for any one of them, we falter – and kids are especially vulnerable. Balancing iron status can change your kid’s life. It may keep them off psychiatric medicine, and will restore their abilities for learning and playing. Check into it!

Lentil soup is a good iron resource.