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Dr Eden, clinical professor of pediatrics, Weill Cornell Medical Center, New York, New York, has been a practicing pediatrician for over 40 years. He has written numerous books on childcare and publications on iron deficiency in children. He also is past
A pediatrician makes the case that increasing efforts on preventing iron deficiency can have the added benefit of preventing lead poisoning.
According to the Centers for Disease Control and Prevention, 2.6% (over one-half million) of children aged 1 to 5 years have elevated blood-lead levels, putting them at risk of permanent brain damage. Although the elimination of lead-based paint in 1978 and leaded gasoline in 1996 have greatly lowered blood-lead levels, some children remain at higher risk for lead exposure, especially those in the low socioeconomic group. Great efforts to reduce exposure to lead continue to be made, but not enough is being done to protect young children from absorbing the lead in the environment by simply increasing our efforts to prevent iron deficiency (ID).
Here are the facts:
There is a clear relationship between ID and lead absorption. Many studies have shown that an iron-deficient young child will absorb more lead from the environment than a child who is iron sufficient. Iron-deficient children have been shown to have higher blood-lead levels than those who are not iron deficient. Iron deficiency increases the gastrointestinal absorption of lead.
Because lead is neurotoxic even at very low levels, it is essential that everything be done to keep blood-lead levels as low as possible. We cannot wave a magic wand to eliminate all the lead around, but we can easily prevent ID in our young children, which will reduce their lead absorption. The current prevalence of ID in toddlers remains much too high, and, in my opinion, is a national disgrace.
What is most troubling is that the Medicaid-eligible children and the Special Supplemental Nutrition Program for Woman, Infants, and Children (WIC)-eligible group of infants and toddlers are most at risk both for lead exposure (often living in houses built before lead paint was outlawed) and for ID attributed to poor nutrition. These children have the highest prevalence rates of ID. A number of studies have documented prevalence rates of ID among these children to be between 10% and 30%.
It is obvious that the current recommendations of the Committee on Nutrition (CON) of the American Academy of Pediatrics (AAP) for the prevention of ID in toddlers have been ineffective and require modification. The committee’s latest recommendations published in 20101 state that “high-risk” toddlers-those from low socioeconomic families, preterm infants, those exclusively breast fed beyond 4 months without iron supplementation, and those exposed to lead, constituting over one-half of all toddlers-as well as those toddlers who do not consume 7 mg of elemental iron each day be tested for ID via serum ferritin, serum iron level, and total iron-binding capacity tests. In my opinion, these recommendations are impractical and much too difficult to accomplish because they are expensive and require venipuncture, and therefore will rarely be followed.
Let me point out that in addition to the relationship of ID and increased lead absorption, there is yet another reason to prevent ID. Over 40 studies have investigated the adverse effects of early ID and neurodevelopment outcome. Both cognitive and motor deficiencies have been documented because of ID and iron deficiency anemia (IDA).
In an attempt to reduce the high prevalence rate of ID and IDA, the local CON of the AAP, New York District II, Chapter 2, endorsed the following recommendation in 2007: “In order to prevent iron deficiency and to reduce lead absorption, all toddlers should be placed on daily supplemental iron (10 mg of elemental iron) when switched to regular cow milk, via a standard iron-fortified vitamin until age 3.” This has been standard protocol in my pediatric office for many years without any problem. It is simple, safe, and effective, without any downside risk.
Unfortunately, the national CON of the AAP has not as yet adopted this recommendation and, therefore, the WIC-eligible toddlers, those most in need, do not receive an iron-fortified vitamin as part of their package. These high-risk children, both for ID and lead absorption, are not being adequately protected.
It is my sincere hope that the CON of the AAP will modify its recommendations for the prevention of ID in toddlers to include the routine use of an iron-fortified vitamin for all children when switched to regular milk.
Our most vulnerable little children must be better protected from ever developing ID. They cannot afford to lose a single precious intelligence quotient point.
1. Baker RD, Greer FR, Committee on Nutrition. Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0-3 years of age). Pediatrics. 2010;126(5):1040-1050.
Dr Eden, clinical professor of pediatrics, Weill Cornell Medical Center, New York, New York, has been a practicing pediatrician for over 40 years. He has written numerous books on childcare and publications on iron deficiency in children. He also is past chairman of the Committee on Nutrition, New York District II, Chapter 2, of the American Academy of Pediatrics.