Your Voice: Hidden toddler iron deficiency: A public health emergency

May 1, 2009

Iron deficiency (ID) is the most common nutritional deficiency in the US, too high by far in toddlers

Unfortunately, this success story does not hold true for toddlers (1 to 3 years old). With the change from breast milk or iron-fortified formula to cow's milk, which contains very little iron, the prevalence of ID and IDA increases dramatically. The exact prevalence remains in doubt. The 1999-to-2002 NHANES data showed that 9.0% of 1- to 2-year-olds had ID and 3% had IDA.1 But three more recent studies2-4 reported about a 30% prevalence of ID, and 10% prevalence of IDA.

Why is this important? Starting with the seminal work of Frank Oski, MD, in 1983,5 there are now at least 40 studies that have investigated the adverse effects of early ID on neurodevelopmental outcome.6 ID and IDA have consistently been shown to be related to impaired mental and psychomotor development. Moreover, these deficits have proven to be long-lasting and perhaps irreversible.7,8

The current American Academy of Pediatrics (AAP) recommendation for the prevention of ID is to screen for anemia (hemoglobin or hematocrit) at 12 and 18 months of age.15 This misses all toddlers suffering with clinically important iron deficiency who are not anemic, as well as those who will develop ID or IDA after 18 months of age.

The recent Pediatric Nutrition Handbook15 acknowledges that "the limitation of screening for iron deficiency by routine hemoglobin testing is that by the time anemia is diagnosed the neurologic consequences have likely occurred....The threat of irreversible developmental delay from a temporary nutritional deficiency emphasizes the importance of prevention."

The Handbook reiterates the AAP Committee on Nutrition statement that recommends universal screening at 12 and 18 months with a screening test that more accurately identifies ID and IDA, but acknowledges that screening is usually accomplished with an inadequate hematologic profile. The AAP Committee on Nutrition "strongly encourages the development of transferring receptor standards for use with this assay in infants and children." However, such a tool is not currently available.

Why wait for the development of transferring receptor standards while so many toddlers will suffer with ID, and the risk of neurodevelopment damage? Whether the prevalence of ID is 9% or 30%, it still remains a serious public health problem that must be addressed.

The AAP NY 2 Committee on Nutrition recommended to its chapter members that all toddlers be placed on daily supplemental iron (10 mg) via a standard iron-fortified multivitamin when they are switched to regular cow's milk, and that this supplementation be continued to age 3.

Chapter members were surveyed to determine the extent of their agreement within this recommendation. Along with the recommendation, we enclosed a postage-paid reply card to the 915 members asking the following question: "Do you agree with the enclosed New York Chapter 2 Nutrition Committee recommendation for routine iron supplementation of toddlers?" The results:

This survey indicates that the great majority of pediatricians who responded support our contention that supplemental iron is required to lower the current unacceptably high rate of iron deficiency in toddlers.

We strongly recommend that iron supplementation for all toddlers become a routine part of pediatric care.

The AAP NY 2 Subcommittee on Toddler Iron Deficiency

Alvin N. Eden, MD, Marc S. Jacobson, MD

Abraham Jelin, MD, Toba Weistein, MD

Michael J. Pettei, MD