Iron

Prepared by Francisca Soto-Aguilar Bralic. MD, Ms Nutrition, Ms Global Public Health

← Back to Overview

 Iron is a vital mineral that plays a crucial role in oxygen transport, energy production, and cellular metabolism. It is particularly important during childhood for growth, brain development, and overall health. Iron deficiency is one of the most common nutritional deficiencies worldwide and can lead to anemia, developmental delays, and cognitive impairments, particularly in children. This guideline provides evidence-based recommendations for iron supplementation in children, based on the U.S. Recommended Dietary Allowances (RDAs), and offers practical advice for healthcare professionals.

Recommended Dietary Allowances (RDA) for Iron in Children

The U.S. Institute of Medicine (IOM) has established RDAs for iron intake based on age, sex, and physiological status. These RDAs are intended to meet the needs of the vast majority of healthy children.

Note: The RDA represents the amount of iron needed to meet the requirements of 97-98% of healthy children.

Upper Limit (UL): The maximum daily intake unlikely to cause harmful effects.

Iron Supplementation Recommendations by Age

Infants (0-12 months)

Rationale: Infants are at high risk of iron deficiency, particularly after 6 months, as their iron stores from birth begin to deplete. Iron is essential for brain development and the prevention of anemia. Exclusive breastfeeding provides adequate iron in the first few months, but complementary foods or formula are necessary to meet iron needs after 6 months. In higher iron deficiency prevalence populations, a prophylactic iron supplement is recommended at this stage.

Recommendation:

• Infants aged 0-6 months: The iron requirement should be adequately provided through breast milk or iron-fortified formula. Premature and low in birth wait infants should be considered for a prophylactic iron supplementation starting age 2-3 months old.
• Infants aged 7-12 months: Iron-rich complementary foods such as legumes, iron-fortified cereals and pureed meats (for children that eat them) should be introduced. Iron-fortified formula can be used if the infant is not breastfed.
• Supplementation: after 6 months of age, it may be recommended for exclusively breastfed infants if complementary iron-rich foods are not introduced after 6 months or if there is a higher risk of iron deficiency based on the health professional assessment, such as prematurity and low-birth-weight infants. Prophylaxis doses for iron supplements are 1-2 mg/kg of elemental iron per day and can be given in separate dosis, with a maximum dose of 15 mg per day. For iron deficiency treatment, doses are 3-6 mg/kg of elemental iron per day.

Summary: if dietary requirements are not met consistently, either through the daily intake of iron-rich foods or iron-fortified formula, and/or if there is a high risk of iron deficiency, supplementation is recommended at this stage and it usually begins at 6 months of age.

Toddlers (1-3 years)

Rationale: Iron is essential for rapid growth, cognitive development, and immune function in toddlers. Iron deficiency in this age group can lead to developmental delays and impaired immune responses.

Recommendation:

Diet: Iron-rich foods such as beans, lentils, tofu, iron-fortified cereals and meat, poultry and fish (for children that eat the latter), should be included in the toddler’s diet. Vitamin C-rich foods (e.g., citrus fruits, tomatoes) can enhance iron absorption. Plant-based iron-rich foods can provide enough iron in a vegetarian or vegan diet, but iron absorption enhancement is encouraged. If cheese and other dairy products are included in the diet, they should be eaten separated from the iron-rich meals, because they can inhibit iron absorption.

Supplementation: If the child has a low iron intake and/or iron deficiency is diagnosed, supplementation may be necessary. Iron supplements should be administered with care, as excess iron can cause gastrointestinal upset or toxicity. The recommended dose for treating iron deficiency anemia is 3-6 mg/kg elemental iron per day in two to three divided doses, with dosing at the lower end for mild anemia and at the higher end for severe anemia.

Considerations: Iron deficiency is common in this age group due to the limited intake of iron-rich foods, so the assessment of intake and serum iron levels when possible is encouraged.

Summary: iron requirements should be met at this stage through the daily intake of iron rich foods and enhancement of its absorption. Supplementation is only recommended in the described cases above.

Children (4-8 years)

Rationale: Iron supports growth and cognitive development in children. Iron deficiency can impair school performance, attention, and cognitive function.

Recommendation:

Diet: Encourage a diet rich in iron-containing foods, such as beans, leafy greens, iron-fortified cereals, and meat, poultry and fish for the children who eat the latter. Plant-based iron-rich foods can provide enough iron in a vegetarian or vegan diet, but iron absorption enhancement is encouraged. If cheese and other dairy products are included in the diet, they should be eaten separated from the iron-rich meals, because they can inhibit iron absorption.

Supplementation: If dietary intake is inadequate or an iron deficiency is diagnosed, supplementation should be considered, especially for children with limited access to iron-rich foods or those at higher risk of deficiency (e.g., picky eaters, low-income households).

Summary: iron requirements should be met at this stage through the daily intake of iron rich foods and enhancement of its absorption. Supplementation is only recommended in the described cases above.

Children (9-13 years)

Rationale: During this period, children experience rapid growth and development, requiring sufficient iron for energy production, immune function, and cognitive development.

Recommendation:

Diet: Encourage a diet rich in iron-containing foods, such as beans, leafy greens, iron-fortified cereals, and meat, poultry and fish for the children who eat the latter. Plant-based iron-rich foods can provide enough iron in a vegetarian or vegan diet, but iron absorption enhancement is encouraged. If cheese and other dairy products are included in the diet, they should be eaten separated from the iron-rich meals, because they can inhibit iron absorption.

Supplementation: If dietary intake is inadequate or an iron deficiency is diagnosed, supplementation should be considered, especially for children with limited access to iron-rich foods or those at higher risk of deficiency (e.g., picky eaters, low-income households).

Summary: iron requirements should be met at this stage through the daily intake of iron rich foods and enhancement of its absorption. Supplementation is only recommended in the described cases above.

Adolescents (14-18 years)

Rationale: Adolescents require more iron due to rapid growth, the onset of menstruation in females, and increased physical activity. Inadequate iron intake can lead to anemia, fatigue, and impaired cognitive performance.

Recommendation:

Diet: Encourage a diet rich in iron-containing foods, such as beans, leafy greens, iron-fortified cereals, and meat, poultry and fish for the adolescents who eat the latter. Plant-based iron-rich foods can provide enough iron in a vegetarian or vegan diet, but iron absorption enhancement is encouraged. If cheese and other dairy products are included in the diet, they should be eaten separated from the iron-rich meals, because they can inhibit iron absorption.

Supplementation: If dietary intake is inadequate or an iron deficiency is diagnosed, supplementation should be considered, especially for female adolescents with heavy menstrual bleeding or restrictive diets.

Considerations: Female adolescents are at greater risk of iron deficiency due to menstrual losses. Parents should be educated on the importance of iron-rich foods, and supplementation should be considered if dietary intake is insufficient.

Summary: iron requirements should be met at this stage through the daily intake of iron rich foods and enhancement of its absorption. Supplementation is only recommended in the described cases above.

Special Populations at Risk for Iron Deficiency

Certain children are at a higher risk of iron deficiency and may require supplementation:

• Premature and Low-Birth-Weight Infants: These infants have lower iron stores at birth and are at increased risk for iron deficiency. Iron supplementation may be necessary after 2-3 months of age.
• Children with Poor Dietary Intake: Children with limited access to iron-rich foods, picky eaters, or those with restrictive diets may need iron supplementation.
• Children with Chronic Conditions: Children with chronic illnesses, malabsorption disorders (e.g., celiac disease, inflammatory bowel disease), or heavy menstrual bleeding may require higher iron intake.
• Children with Lead Exposure: Lead interferes with iron absorption and increases the risk of iron deficiency anemia. Screening for lead exposure is recommended in at-risk children.

Iron Supplementation Safety and Monitoring

• Toxicity: Iron toxicity is a serious concern, especially in young children. Accidental overdose of iron supplements is one of the leading causes of poisoning in children under 6 years of age. Symptoms of iron overdose include nausea, vomiting, diarrhea, and abdominal pain. Emergency medical attention should be sought immediately in case of overdose.
• Supplementation Dosing: The usual dosage for iron supplementation in children is 3-6 mg of elemental iron per kilogram of body weight per day. For example, a 20 kg child may need 60-120 mg of elemental iron per day. Iron supplements should be given on an empty stomach to enhance absorption, but they may be taken with food if gastrointestinal discomfort occurs.
• Monitoring: Iron status should be monitored through hemoglobin, hematocrit, and ferritin levels in children receiving supplementation. Children who are at risk for deficiency should be regularly assessed for signs of anemia (e.g., fatigue, pallor).

References

1. Institute of Medicine (US) Panel on Micronutrients. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, lodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc. Washington (DC): National Academies Press (US); 2001. 9, Iron. Available from: https://www.ncbi.nlm.nih.gov/books/NBK222309/
2. McDonagh, M., Blazina, I., Dana, T., Cantor, A., & Bougatsos, C. (2015). Routine Iron Supplementation and Screening for Iron Deficiency Anemia in Children Ages 6 to 24 Months: A Systematic Review to Update the U.S. Preventive Services Task Force Recommendation. Agency for Healthcare Research and Quality (US).

← Back to Overview