The importance of administering iron to infants

Why do some countries recommend preventive iron administration?

Primary prevention is recommended in some countries in the world – this means prevention through treatment, prior to the development of a deficiency or illness. Nice.
Not all countries follow this recommendation. It could be that in some countries it is recommended because of certain populations that reside in it, populations that are more prone to developing iron deficiency. Nonetheless, iron deficiency anemia is the most common nutritional deficiency in children (regardless of whether they are at high risk or not), and it is related to delayed development and cognitive impairment in infants.

How common is iron deficiency in the world?

The prevalence of iron deficiency in infants varies around the world.
It is important to keep in mind that babies who were born term have enough iron stores for 4 months, depending on the iron stores the mother carried and transferred to the infant through the placenta, and afterwards through breastfeeding. Following the age of 4 months, the infant becomes dependent on the iron content of the food they consume and their ability to absorb the iron from the food.

It is important to also note, that when it comes to iron intake, breastmilk is preferred over formula because the absorption of iron in breastmilk fed infants is higher than that in formula-fed infants. Starting the age of 6 months (or sometimes 4 months, as you will learn from reading this website) you can include iron-rich foods in a child’s diet that help with the absorption of iron (meat, iron-fortified cereals, legumes, vegetables and fruits).

When is the administration of iron supplements recommended?

In healthy children, it is recommended to start supplementing with iron at the age of 4 months.

What is the dose that is recommended for healthy infants that were born term?

7.5 miligrams in the first two months (from the age of 4 months to 6 months) and then 15mg until the age of 18 months or until a complete blood count is performed and normal results are obtained.

Are there certain populations of infants that should receive iron at a younger age?

Infants that were born preterm (prior to the 37th gestational week), should receive iron starting the age of 2 weeks at a dose of 2mg/kg of body weight unless there were other instructions given by the hospital upon discharge or by the physician. The maximal dose for infants under the age of 6 months is 7.5 mg per day, and over the age of 6 months it is 15mg per day.

How many drops contain 7.5 (or 15) mg?

There are many different iron products in the market. Each one of these products has a different concentration. It is important to check for the iron concentration in each of these products and to find out how many drops contain the dose that you need.
For example, there is a product in the market that has 2.5mg in each drop. So, an infant between the age of 4 and 6 months would need 3 drops in order to receive 7.5mg.

Realistically, how can iron be given to an infant? Where and when?

Parents can decide the time of day at which they want to give their child the iron. However, because it is important to have some sort of routine so that you don’t forget, it is preferable to have a set up including a specific time every day. In addition, because the iron can get the baby dirty, many parents choose to give it to their child in the evening, during bathtime. Also, in addition to the hygiene advantage, administering iron at the same time every day in a ritual helps make sure you don’t miss out on any days.
Something that is very important, relevant to some of the products available in the market, and not emphasized enough, is that for some of the products that are available in the market the iron will not be absorbed well if it is consumed together with milk (both breastmilk and formula). This is because the iron binds to the calcium in the milk. Therefore, depending on the product that you may have at home, I suggest checking whether it is important to separate the iron from milk consumption by at least one and a half hours. Administering it at a shorter interval will cause a decrease in the child’s ability to absorb the iron.
On a personal note, in our house, we give the iron during the evening hours, together with vitamin D which we will elaborate on in a different chapter, during bathtime, after which we feed the baby and put them to sleep.

What kind of side effects can iron have?

I think that if you google it, you will learn that there isn’t a single side effect that has not been attributed to those poor 7.5mg of iron that we attempt to give our baby once a day. It is true, iron can cause abdominal discomfort and mild constipation. But many things happen to a baby around the age of 4 months, and associating abdominal pain and constipation specifically to the administration of iron is extreme, in my opinion. If abdominal pain or constipation do develop, and they seem to be directly associated to the administration of iron, you can reduce the dose of the iron for a short period of time or divide the daily amount required to two doses per day.
In situations at which the baby does not receive iron for one reason or another, I recommend making sure to feed them iron rich foods during their first year of life (and in the following years) – breastmilk (as opposed to formula), formulas that are iron rich (all the formulas that are sold nowadays have a generous amount of iron) and afterwards iron rich food according to the child’s age.

Until what age are iron supplements recommended for babies?

Until the age of one and a half years.

Can we obtain a complete blood count to shorten the length of time that is iron needs to be given?

Yes. You can obtain a complete blood count (with the help of a finger prick blood sample) starting the age of 9 months (preferably closer to 1 year of age) in order to assess the iron levels and stores in the body). If a complete blood count is obtained, we will assess three different parameters: hemoglobin, mean corpuscular volume (MCV) – which indicates the average size of the red blood cells, and in cases of iron deficiency, this parameter is reduced, and the third parameter is red cell distribution width (RDW) – the distribution of sizes of red blood cells in the body.

Hemoglobin – a value that is lower than 11 gram/deciliter indicates anemia.
MCV – a value that is 70 or higher is normal. If the value is lower than that, then it could indicate iron deficiency, with or without anemia.
RDW – a value of 16% or lower is normal. If the value that is obtained is higher than that then it could indicate iron deficiency, with or without anemia.

Is there another reason to obtain a routine complete blood count around the age of one?

No. The purpose of the complete blood count around the age of one is only in order to determine, in an indirect way, the iron levels in the body, so there is no other medical need reason for this test or for assessing the remainder of the parameters.

When should a complete blood count test be delayed?

This test should not be done to determine the hemoglobin and iron levels during an acute infection, and up to 2 weeks following the infection.
I don’t know what parents of children experiencing their first winter, who are ill every 2 weeks, do…

So, what do we do if the blood count is normal?

If the blood count is normal, we can continue to give 15mg of iron until the age of one and a half years.

What happens when there is anemia or iron deficiency?

Let’s remind ourselves of what these two mean:
Anemia – an iron level that is less than 11mg/deciliter. In these situations, the nurse will guide the parents as to what kind of nutrition is appropriate for the child and how to administer iron and will make sure that the child is referred to their physician who will consider further investigations and monitoring. Obviously, in these situations the parents have to continue giving the iron until otherwise instructed by the physician.
Iron deficiency (with or without anemia) – let’s keep in mind two options:
Firstly, we will look at the MCV – any value that is under 70. In such cases (whether the child has or does not have anemia), you should refer to the primary physician and consider further investigation and monitoring.
The second parameter to be looked at is RDW – any value that is above 16%. In such cases (whether the child has or does not have anemia), you should refer to the primary physician with a similar purpose as mentioned above.

What will the physician recommend when a child has anemia and/or iron deficiency?

The physician will probably do several things, including:
• Assess, together with the parents, how well they have been administering the primary prevention (have they been giving it at all, is it being given together with milk meaning the absorption is not right, what other iron-rich or iron-poor foods is the baby consuming).
• Consider the possibility of other causes for the abnormal lab results. There are other medical conditions that could cause anemia or a low MCV (mainly thalassemia and chronic diseases).
• Usually recommend the continuation of iron for several months, and then recommend repeating the blood work or doing further investigations.

In summary, the management of iron can be slightly complex but I tried to simplify it for you and I hope that when looking at your child’s complete blood count taken around the age of one, you are now able to tell what the next best step is on your own.
And now that we’re done with this topic, I suggest you move on to reading this post about iron deficiency and anemia in children.
Good luck!