Iron and Vitamin D supplementation in children/infants


I hope by now you have heard about the AAP’s vitamin D recommendation for young children.  In addition to vitamin D, the AAP will be publishing an updated report on iron recommendations for children in November.  Here is a sneak-peek.  But first, a little background info.

Why is iron important?

Iron is used by the body in many ways.  Specifically, iron is used to make red blood cells. The red blood cell moves oxygen throughout the body.  In order for the red blood cell to attract oxygen molecules for the ride, an “oxygen magnet” called hemoglobin is made for the cell using iron as a key ingredient.  If a person does not have enough iron to make functioning red blood cells, the body will not produce an adequate amount of these cells.  This leads to a condition called iron deficiency anemia (IDA).

We also know that iron is important for brain development. Without appropriate levels of iron in a young child, there may be irreversible neurodevelopmental consequences.  Since iron deficiency (ID) is the most common nutrient deficiency in children worldwide and evidence of iron’s importance for a growing young child’s body is so significant, the AAP hopes these updated recommendations will decrease the presence of ID and IDA.

What is “anemia”?  How is iron related to anemia?

Anemia is a term that reflects the amount of hemoglobin in the body.  If a person has  low level of hemoglobin, they are considered anemic.  Hemoglobin is the “oxygen magnet” that lives in the red blood cell.  Every hemoglobin molecule is made using iron.

In the past, if a child was anemic, it was assumed that the child was also iron deficient.  This assumption was made based on the knowledge of the high prevalence of IDA in kids.  After assessing the recent review of data, researchers were surprised to find that most kids that were iron deficient were not anemic.  Of the kids who were anemic, only 40% of those kids had anemia due to ID.

Based on the new analysis, the AAP has made the following recommendations:

  • Exclusively breastfed, full-term infants have adequate iron intake for the first 4 months of life.  After this time, the iron content in breast milk decreases and the infant’s larger body requires more iron for optimal growth.  Therefore, all infants over the age of 4 months who are getting at least 50% of their intake with breast milk should receive a liquid iron supplement. Once adequate iron-containing foods are added to baby’s diet, the supplementation may be discontinued.  Goal supplementation = approximately 0.5 mg per pound of body weight per day.
  • All breast-feeding pre-term infants (before 37 weeks gestation) should receive an iron supplement from 1 month of age until the age of 1 year. Iron is passed from mother to child in the womb during the last trimester.  If a baby comes too early, they miss the time needed for iron to be shared.  Goal supplementation = approximately 1 mg iron per pound of body weight per day.
  • All formula-fed (term and pre-term) infants should remain on an iron-fortified formula until 12 months of life. This will be adequate intake without any additional supplementation.
  • Infants 6-12 months of age should regularly eat iron containing foods.  Adding iron-containing foods as “first foods” is important.  If iron-containing foods are not routinely part of the child’s diet, a liquid supplement should be added. Recommended daily intake is 11 mg of iron for this age group.
  • Children 1-3 years of age routinely need foods containing iron.  Vitamin C is also important in toddler diets since vitamin C helps iron get absorbed into the body from the digestive tract.  Milk is very low in iron.  Drinking over 24 ounces of milk per day increases ID risk. Recommended daily intake is 7 mg of iron for this age group.

In addition, I would add that teens also need to review their iron intake.  Teen boys need 12 mg of iron per day, while teen girls need 15 mg of iron per day.

It is best to support nutritional requirements with whole, natural foods.  However, when was the last time you were able to get a toddler to eat a plateful of liver and lima beans?  Our typical American diets are low in foods with iron.  It is appropriate, therefore, to supplement our young kids with quality vitamins if natural foods containing iron are not a large part of the diet.

As a result of these recommendations, it is possible that your provider will be asking more questions about your child’s health and diet history to determine his or her risk of iron deficiency. Based on your child’s risk factors, a blood test to determine iron status is recommended after the first birthday, or sooner if needed.  If iron supplementation is recommended, additional testing may be requested after 4 weeks to determine if the supplementation is effective.  Your provider will be able to specifically direct any lab testing or supplementation needs for your family.  Please ask at your child’s next check-up what your doctor suggests.

P.S. Iron can be toxic in large amounts.  If you choose to supplement your kids, keep iron formulations out of kids’ reach to decrease the risk of overdose.



Vitamin D: On the Double

If you think your child is getting enough vitamin D by just drinking milk, you’re probably wrong. Recent studies show that most children aren’t getting enough of this essential vitamin. In October 2008, the American Academy of Pediatrics (AAP) responded by doubling the amount of vitamin D it recommends for babies and children to 400 International Units (IU) per day.

Why Vitamin D?

Most often associated with milk and sunlight, vitamin D hasn’t been top-of-mind for parents in recent years. Common wisdom says that if you’re child drinks milk and plays outside, he’s getting what he needs, right? Surprisingly, not necessarily. “We’re seeing evidence of vitamin D deficiency in infants and children of all ages as well as adolescents and adults,” says Carol Wagner, M.D., FAAP, professor of pediatrics at the Medical University of South Carolina. “We know more about vitamin D than we did even five years ago. Because of lifestyle changes and sunscreen usage, the majority of the population shows signs of deficiency as determined by measured vitamin D levels in blood.”

Vitamin D helps ensure the body absorbs and retains calcium and phosphorus, both critical for building bone. A vitamin D deficiency can lead to rickets, a bone-softening disease that continues to be reported in the United States mostly in children in the first two years of life. At greatest risk for rickets are infants exclusively breastfed who do not receive a daily vitamin D supplement.

“There is epidemiologic evidence that vitamin D not only makes for strong bones, but may play a role in preventing some chronic diseases later in life, including those involving the immune and cardiovascular systems,” explains Frank R. Greer, M.D., FAAP, professor of pediatrics at University of Wisconsin School of Medicine and Public Health.

Based on these findings the AAP has changed its previous recommendation of 200 IU per day to 400 IU a day beginning in the first days of life. “We are doubling the recommended amount of vitamin D children need each day because evidence has shown this could have life-long health benefits,” says Dr. Greer, chair of the AAP Committee on Nutrition and co-author of the AAP’s clinical report on vitamin D. “Supplementation is important because most children will not get enough vitamin D through diet alone.”

Supplements for All

The AAP recommends vitamin D supplements for infants, children, and adolescents, including those who are breastfed. “Breastfeeding is the best source of nutrition for infants,” explains Dr. Wagner, a member of the AAP Section on Breastfeeding Executive Committee and co-author of the AAP’s clinical report on vitamin D. “However, it is important that breast-fed infants receive supplements of vitamin D. Until it is determined how much vitamin D a nursing mother should take, we must ensure that the breastfeeding infant receives an adequate supply of vitamin D through a supplement of 400 IU per day.” Once the child is weaned, a vitamin D supplement is needed throughout childhood and adolescence as well, she adds.

For formula-fed babies, the requirements are the same. Unless the child is drinking 32 ounces of infant formula per day, a vitamin D supplement is required.

Giving Supplements

When it comes to giving your child a vitamin D supplement, there’s nothing new about the process. “Any chewable multivitamin supplement for kids that contains 400 IU of Vitamin D is acceptable,” says Dr. Greer. “There are several liquid vitamin preparations for infants that contain 400 IU vitamin D per dose as well. Chewable vitamins are generally regarded as safe for  children over the age of three who are able to chew hard foods and candy.”

For breast- or bottle-fed babies, liquid supplements are the best option. “There are liquid preparations that give the recommended intake of 400 IU in 1/2 or 1 mL, which are considered to be safer by some,” says Dr. Wagner. “There are also liquid drop solutions available that provide one drop that equals 400 IU per day. The care provider can put the vitamin D drop on an index finger and then place the finger in the baby’s mouth,” she suggests. “Alternatively, the drop can be put on a pacifier or breast and then when the infant sucks the pacifier or breast, the infant receives the vitamin.”

As with all medications and supplements, vitamin D supplements should be kept out of a child’s reach. “The risk with drop solutions is that an infant or other children in the house could receive too much vitamin D,” Dr. Wagner says.

Finding D Naturally

In addition to vitamin supplements, enriched foods are another way to increase the vitamin D in your child’s diet. Look for foods fortified with vitamin D such as milk, cereal, orange juice, yogurt, and margarine.

Vitamin D is found naturally in only a few foods — they include oily fish, beef liver, cheese, egg yolks, and some mushrooms. Oily (or fatty) fish are one of the best sources of the vitamin. For example, 3.5 ounces of cooked salmon offers approximately 360 IU (about 90 percent of your child’s daily recommended value) of vitamin D per serving. Other examples of oily fish include tuna, mackerel, trout, herring, sardines, kipper, anchovies, carp, and orange roughy.

Quick Tips: The ABCs of Vitamin D

How to make sure your child is getting enough vitamin D:

  • Breastfed and partially breastfed infants should be supplemented with 400 IU a day of vitamin D beginning in the first few days of life.
  • All non-breastfed infants, as well as older children, who are consuming less than 32 ounces per day of vitamin D-fortified formula or milk, should receive a vitamin D supplement of 400 IU a day.
  • Adolescents who do not get 400 IU of vitamin D per day through foods should receive a supplement containing that amount.
  • Children with increased risk of vitamin D deficiency, such as those taking certain medications and with chronic diseases such as cystic fibrosis, may need higher doses of vitamin D. Consult your  pediatrician.

Quick Tips: Adding it Up

Here’s a look at some food sources of Vitamin D:


Food IU per serving* Percent DV**
Cod liver oil, 1 tablespoon  1,360 340
Salmon, cooked, 3.5 ounces  360  90
Mackerel, cooked, 3.5 ounces  345  90 
Tuna fish, canned in oil, drained, 1.75 ounces 200 50
Sardines, canned in oil, drained, 1.75 ounces  250  70
Milk (nonfat, reduced fat, and whole), Vitamin D-fortified, 1 cup  98  25 
Margarine, fortified, 1 tablespoon 60  15
Ready-to-eat cereal, fortified with 10% of the Daily value for vitamin D, 0.75-1 cup 40 10
Egg, 1 whole (vitamin D is found in yolk)  20 
Liver, beef, cooked, 3.5 ounces  15  4
Cheese, Swiss, 1 ounce  12 
*International Units
**Daily Value based on recommended 400 IU for children.Source: National Institutes for Health, Office of Dietary Supplements

Disclaimer: The information provided on this site is for informational purposes only and is not intended as a substitute for advice from your physician or other health care professional or any information contained on or in any product label or packaging. You should not use the information on this site for diagnosis or treatment of any health problem or for prescription of any medication or other treatment.