Paediatric Nutrition

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Tag: iron deficiency anaemia

Iron Deficiency Anaemia in Infancy

Iron deficiency anaemia (IDA) is the most common nutritional problem affecting infants with 60% of 6-12 month old babies in the UK having low dietary iron intake, a key risk factor for developing IDA. Early childhood is a time of vulnerability as iron deficiency anaemia in this period may be associated with impaired development, especially if a baby had low iron stores at birth eg. as a result of prematurity or low birth weight. It’s also a time of rapid physical growth, brain and nervous system development, and a time when dietary iron needs are at their highest. Various risk factors are known to contribute: particularly premature birth, low birth weight, maternal iron deficiency and poverty.  Iron supplementation may not adequately correct IDA in more extreme cases, and so infant feeding practices including the introduction of solids are important considerations. Iron supplementation requires medical or dietetic guidance, because iron overload can be harmful. The  body is not able to excrete or get rid of excess iron, which is stored in the liver and spleen.  For this reason, iron absorption is limited (by the gut) to around 15-20% and this becomes relevant when thinking about choosing iron-rich foods to offer, whether plant or animal and which foods improve or limit absorption. Here I provide some information about nutritional needs for iron during infancy, dietary sources of iron and infant feeding practices: the introduction of iron-rich foods.

Infants’ Nutritional needs and Dietary sources of iron

Iron is an essential micronutrient required to make haemoglobin, brain and nervous system development, and protection from infection. Iron is the red pigment in haemoglobin, which carries oxygen around the body within the red blood cells. IDA means that the blood carries less oxygen than the body needs and infants with IDA will be pale and tired, have poor resistance to infection, and their general health, appetite, and vitality is poor.  Typically, infants don’t show any signs in the early stages of IDA, and it commonly goes undiagnosed until they become symptomatic. Iron needs are highest in infants aged 6-12 months, term babies will used up all their iron stores, which built up during the last trimester of pregnancy, and dietary iron needs rapidly increase. Introducing iron-rich foods is critical at this age; not only does this provide essential dietary iron, but introducing those foods at this age helps establish familiar tastes, smells and textures of iron-rich foods like red meat, liver, egg yolk and also apricots, dried fruits, green vegetables, lentils, avocado, oily fish, seed and nut butter. Many cereals are fortified with iron, and since 1998, white wheat flour is fortified with 1.65mg iron per 100g.  7.8mg  of iron is the reference daily intake for a healthy, term baby. The reference daily need for women of child bearing age is 14.8mg.

Infant Feeding practices and the Introduction of Iron-rich foods

Breast-fed infants need iron-rich foods on a daily basis from the weaning period 6-12 months because breast milk contains very little iron.  Formula-fed infants also need to become familiar with iron-rich foods, even although iron-fortified formula will meet their iron needs beyond 6 months. Becoming familiar with the smells, tastes and textures of iron -rich foods like red meat, egg yolk and green vegetables, at an early age will help acceptance of these foods, prior to natural developmental phase of food refusal during toddlerhood.  Toddlers who have eaten a wide variety of foods from 6-12 months (in the sensitive window) are less fussy because these foods are more familiar and they have practiced eating them.  Those infants will also have developed a range of feeding skills, which supports eating better during toddlerhood.  Drinking iron-fortified formula does protect against IDA, however, for longer-term feeding practices, introducing these more challenging tastes and textures during the sensitive window, provides more varied and robust nutrition going forward. First formula milks, those with a higher ratio of whey, are best suited for all babies until 1 year for many reasons, with improved absorption of nutrients including iron.

A consultation on the availability of NHS gluten free foods on prescription has been launched by NHS England and will run from 31st March until 22nd June 2017.  Please respond with comments, ideas or experience if you or someone you care for has Coeliac Disease and needs a gluten free diet.

Background facts

  • The gluten free diet is the only available treatment for Coeliac Disease, a life long auto-immune condition affecting 1 in every 100 people, with new cases increasing year-on-year
  • Strict adherence to the diet limits complications of the condition in children such as growth faltering, iron deficiency anaemia and lactose intolerance
  • Approved gluten free foods on prescription include staples such as bread, pasta, flour, rolls and pizza bases and the monthly allowance is controlled by National Prescribing Guidelines
  • Gluten free foods are one of a range of “low-value” treatments being targeted to reduce the NHS prescribing budget
  • 20% of Clinical Commissioning Groups (CCGs) in England have reduced or stopped  prescribing gluten free foods to help balance their books, disproportionately affecting those on low incomes

A spokesperson for NHS England said

“The increasing demand for prescriptions for medication that can be bought over the counter at relatively low cost, …  underlines the need for all healthcare professionals to work even closer with patients to ensure the best possible value from NHS resources, whilst eliminating wastage and improving patient outcomes.”

A number of options have been proposed

  1. no changes to be made to NHS gluten free foods on prescription
  2. end NHS gluten free foods on prescription
  3. restrict NHS gluten free foods on prescription to essentials eg. bread, flour
  4. alternative scheme to support cost difference between shop bought gluten free foods and their gluten containing counterparts

Innovative alternative pilot scheme
A pilot scheme is underway in Yorkshire, where 100 people following a gluten free diet have been issued a chip and pin card providing the cost difference between gluten free foods and the gluten containing counterparts.  Benefits include having access to a wider range of foods; purchasing gluten free foods can be integrated into the usual shop; potential costs-savings to NHS and time-saving for GPs and dispensers.  However, for some people with reduced mobility or with poor access to supermarkets, they are likely not to benefit in this way.   The full evaluation of this pilot scheme will be available later this year.

If you have been affected by CCGs reducing or stopping gluten free foods on prescription please contact for help and support.

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foods rich in iron

All children need regular sources of foods rich in iron, especially in infancy, toddlerhood and the teenage years. Absorption of iron from food is variable, but is typically around 15-20%.  Iron absorption happens in the gut and depends on a number of changing factors: iron status, general health and age.  The availability of iron in the food itself is known as bioavailability.  Infants, toddlers and teenagers have high nutritional needs for dietary iron, and can be at risk of iron deficiency anaemia.  We depend on iron for transporting oxygen in the body, for brain development, concentration and stamina.

Maximise foods rich in iron with these top tips
  • Avoid giving milk with a meal as the high calcium content of milk reduces iron absorption
  • Do include fruits and vegetables with each meal; the Vitamin C content increases iron absorption
  • Avoid giving children tea; the tannins in tea bind iron and reduce its absorption
  • Foods containing haem-iron such as those in foods of animal origin like red meat and eggs are absorbed more effectively
  • Foods containing non-haem-iron found in foods of plant origin like cereals, fruits, nuts, pulses and vegetables are less effectively absorbed
  • Eating red meat twice a week, 3 eggs per week, regular beans, pulses, nuts, fruits, cereals and vegetables will meet the needs of most children
  • Other plant sources of iron include apricots, blackcurrants, figs, prunes, cocoa, dark green leafy vegetables, lentils, edamame beans, kidney beans, cashew nuts, peanuts, tahini, sesame seeds, pumpkin seeds, oats, wholegrains,  quinoa, fortified cereals eg. ready brek, weetabix
  • Vegetarian and vegan school children generally have lower iron status but do get sufficient iron from beans, pulses, soya mince, nuts, nutritional yeast with iron, tofu fruits, cereals and vegetables – vitamin C intake is a valuable addition to enhance absorption for this group
  • Toddlers can reduce the risk of iron deficiency by having water with main meals instead of milk