EP 31: Iron Deficiency in Toddlers: Why “Borderline” Is Not Good Enough

Could your toddler have low iron even when you are offering healthy, iron-rich foods? Dr. Liz Daniels shares her personal experience with her son’s low hemoglobin and explains why iron deficiency is common, treatable, and never a sign that a parent has failed. You will learn why borderline hemoglobin should not be ignored, how iron supports brain development and growth, and why food alone may not correct an existing deficiency. Dr. Liz also explains the difference between ferritin and hemoglobin, when supplements may be needed, and why breastfed babies can face a higher risk. Plus, she clears up the common belief that protein and iron are the same. This caring, practical episode will help you speak with your child’s healthcare team and make informed feeding choices.

What You’ll Learn:

• Why iron deficiency can happen even when parents do everything right
• Why borderline hemoglobin should not be ignored
• How iron supports brain development, growth, and healthy red blood cells
• The difference between low ferritin and low hemoglobin
• Why iron-rich foods may not be enough to correct a deficiency
• When iron supplements may be needed for babies and toddlers
• Why breastfed babies may have a higher risk of low iron
• How vitamin C can help the body absorb iron from food
• Why protein and iron are not the same
• When follow-up testing can confirm that iron levels have improved

Episode highlights:
(0:00) A parent’s personal experience with low hemoglobin
(3:02) Why iron deficiency is not your fault
(3:44) How iron supports growth and brain development
(5:17) Infant iron stores and major risk factors
(9:19) Why borderline hemoglobin needs attention
(13:08) Iron-rich foods, absorption, and supplements
(16:51) Treating and retesting until the gap is closed
(19:27) Iron supplements for breastfed babies
(21:45) Why protein and iron are not the same
(26:04) Five key takeaways for parents

NEW COURSE! "Read the Pattern: Feeding Your Baby 0–4 Months" — because a healthy relationship with food starts earlier than most people think. Course Link!

Disclaimer: This podcast is for educational purposes only, not medical advice.

Transcript

SPEAKER_00 0:00

My son's hemoglobin came in at 10.7, cut off as 11 for normal. I still remember it 15 years ago. And the reason this mattered to me is because I thought I'd done everything right. I was a dietitian before I'd gone to medical school. I'd breastfed him exclusively. And then we started doing solids, and I gave lots of iron-rich foods. I knew what I was doing, and he still came in low. And I had a hard time not taking it personally. And if this has been you, I want you to listen to the full thing because today we are going to talk about not only the updated iron deficiency guidelines, but the top things that I see parents misunderstand a little and I don't want you to. So stick around because we are going to talk all things iron deficiency for the first couple of years of life. And you know, this happens like all the time. And if you've ever been told, oh, it's borderline, we're just gonna watch it. I need you to hear this before you do anything else. Borderline is not enough, okay? We need this for brain development, and there's a reason I care, and there's a reason I want you to know more. Welcome back to the Nutrition for the Earliers podcast with me, your host, Dr. Liz Daniels. I'm a nutrition first kind of pediatrician, and this podcast is for the parent who's second-guessing their grocery cart, worrying if their kid is gonna end up with the same food struggles that they once had. I love getting into the weeds of what kids actually need and then putting it into context of where they're at in growth and development so you can let go of the shame and guilt and focus on what actually moves the needle together. Let's get into it. Today we're gonna talk about the top five things I wish more parents knew about iron deficiency anemia before they walk in for that one-year visit. Because knowing this is really empowering and it can make a big difference for your kids' health in the long run. Welcome back to Nutrition for the Earliers Podcast. I'm your host, Dr. Liz Daniels, board-certified nutrition-focused pediatrician, here to give you guilt-free guidance for feeding your family well. I love the one-year visit. Okay, it's so much fun because we get to talk about the birthday cake and the theme of the party, what presence they actually enjoyed, or maybe just the wrapping paper and milestones. Like there's so much to talk about. And inevitably, there are things we have to talk about, like iron deficiency anemia, because we screen hemoglobin at the one-year visit for most kids. Sometimes we do it at the nine-month visit, but for the most part, it's that one-year checkup. And like in my case, I see a lot of families who do all the things right and it still happens. And that's not failure. What I want you to take away from today is more that you there are things you can do to help your kid and set them up for success, but really the more important piece is making sure we really treat this well, because iron metabolism is actually pretty complicated and it's not easy to fit it into the well visit when we have a lot of other things going on. So it takes some conversation. And here we are. You know, and I think a lot of families will find themselves in this situation. And the first thing I hear them say is actually takeaway number one, it's not your fault as a mom, especially if you're like, well, this makes sense because I was iron deficient. That's not why your kid's iron deficient. Okay. So it's not genetic. There are some genetic causes of anemia, but when we're talking about iron deficiency anemia, this is dietary. It's not something you gave your kid because you had a challenging delivery or pregnancy or because you were anemic. It's purely nutritional and we can fix it. So, number one, not your fault. And part of the issue is that we care because iron deficiency has somewhere, it has a lot of jobs. Okay. I research that. But we care because iron deficiency needs to be treated. Iron is used for a lot of jobs in our body. We use iron as, you know, developing neurotransmitters. We use iron for brain cells. We use iron for muscle contractions and red blood cells to carry oxygen. We use iron in muscle tissue. You use iron in lots of things in our body. And when you have a baby that's growing rapidly, there's a lot of cells that are getting turned over, made new. There's a lot of repair to the tissue, and there's a lot of brain development. And because you have all of those things happening at once, you have a unique situation in their life where they have a higher demand for iron than they probably will for the rest of their life, assuming they don't go on to have children of their own. That's another conversation. That's also why moms end up with anemia. But for the sake of this conversation, take away from it that it's a cluster of situations happening all at once. Your baby's need becomes really high from four to six months, all the way up to about a year. And so, in that time, if there's a gap in what they're getting and what they need, then we don't want to miss it. Because guess what? Your kid's going to continue to grow. And the hard part is that there's not a lot of symptoms for iron deficiency to appear. So you don't know unless you look. Now, one of the things that I want to talk about is like where this comes from. Like, let's talk a little bit earlier. So before they're even born, your baby is getting iron really throughout the pregnancy from mom's diet, but at the end of the last trimester, your baby's getting a big shift in iron from you. So it passes through the placenta, gives the baby kind of um like a full gas tank before they're born. And if they're in the camp of babies who don't get to make it all the way till 40 weeks of delivery, then they may be at higher risk because they missed out on this gifting opportunity that your body naturally does for them. And so preterm babies are at higher risk for iron deficiency. That's one thing to know. And we define preterm as really anything under 36 weeks of life, 37, 36 weeks of life. But the other thing here is that a traumatic birth can be really challenging on both mom and baby. That can increase your risk a little bit. And a lot of practices, a lot of birthing hospitals are now doing delayed cord clamping, which helps support babies even further because that allows a last little bit of blood to flow, which is really good and protective. But if your baby didn't make it all the way to term, then hopefully they are given iron drops or suggested to get iron supplementation in the very beginning, especially if they're breastfed. But let's talk a little bit more, too, about what I mean by that. So they're gifting them this iron. Well, where does it go? Well, it's actually stored. It's a mineral that is stored in our body in the liver. And I like to describe this sort of like a gas tank. You know, you have full to empty. And if the baby gets a full gas tank before they're born, then they're going to be able to use that gas tank throughout the first year of life as they're growing when their demands are higher. In the very, very beginning, your newborn doesn't actually need a lot, right? Like they're getting little bits of milk. Slowly, they're getting more and more volume as they get bigger. And in breast milk, there's not a whole lot of iron, but it is very bioavailable. So our babies are amazing and we're designed really well. So these babies get a small amount, like about a third of a milligram every day. And that's all they need. And that's fine because that's enough to support both their growth needs and their brain development needs. However, once they get bigger at about four to six months, their need actually increases a lot. And we really like to see that up to about 11 milligrams. There's some nuance to this number. Part of this is because we have to achieve this through often non-heme sources. Um, but just putting out there that our babies need a lot more iron when they are six to 12 months. Um, and that can't be fully achieved by that gas tank anymore. So we've at that point now pretty much emptied the gas tank and we have to refill it up or we have to get enough in the diet. And this can be really hard to do. Now, we obviously encourage breastfeeding and it's fantastic. I was in that camp as well. But the challenge can be that once your baby needs more iron and they're breastfed, if they're not getting enough in their diet, it can create an opportunity for a nutritional gap. And I think a lot of babies are really good at eating solids, and a lot of parents are really driven to, you know, they've heard the phrase food before one is just for fun, which that's a whole nother conversation. Or they even heard, yes, you need your baby needs iron-rich foods. That's great. But still, absorption is complicated. So I knew my kid needed iron, and I teach my patients this, and it still happens because we don't always absorb everything that we get in our diet. It's kind of complicated. And so that's why we screen, because inevitably there's going to be a baby somewhere who's low. Well, the reason this also matters, the next step in this thought process is that if we don't supplement and if we don't fix this, then there are real consequences. Which leads me to number two. And that is borderline is not good enough. We want to treat iron deficiency anemia. Sometimes I'll have families that tell me, oh yeah, my kid was like borderline, like right at like 10.8, 10.9. So we just kind of watched it, no big deal. And then we recheck it 15 months, and I guarantee every time they're gonna be lower than they were before, which is not helping us. This is tricky because iron deficiency and iron deficiency anemia are not the same thing. Okay, if we're borderline low hemoglobin, then our gas tank is done empty. So bear with me here. Okay. Ferritin is our indicator, it's our storage form of iron. And the trick here is, or the tricky part is that we don't have a very good test to check ferritin. We have to do a blood draw from the arm, from a blood, from a vein. And we have a different indicator called hemoglobin that we can check. And that's what we do in our office. That's what most practices do. And that's like a little toe prick where we're looking and we're trying to make sure that the hemoglobin is above 11 or so in the first year of life. Now, the thing is, hemoglobin is downstream your low ferritin. So, in order to get a low hemoglobin, you have to have depleted your iron stores because you use iron to make new red blood cells. So if you don't have enough iron to make new red blood cells, then your hemoglobin will come down. So if you have a low hemoglobin or even a borderline hemoglobin, it's really because your ferritin's probably low, very low. And if we miss this, then you don't get more just from the air. And in your diet, you really need to supplement in order to close the gap, which I'm gonna talk about it a little bit more in a minute. But the point here is that if your hemoglobin is borderline or low, so 11 or lower, it's not good enough. And we really should treat because your baby needs ferritin more than just a little bit, needs ferritin for more brain development. And if we wait to treat this until years down the road or even six months down the road, we've missed an opportunity to make the things that we need to make right then and right there. Here's why this matters untreated iron deficiency leads to cognitive delay and cognitive decline, actually, appreciable IQ point differences between kids who have normal iron levels. And especially in this infancy period, because we use iron for brain development. And what are we doing a lot of developing our brain? And so here's the key. If you wait to close that gap, then you miss out on some of that opportunity. You will get recovery of ferritin, but you can't fully recover the opportunity you missed. And I'm not saying this to scare you. I'm saying this because iron deficiency really is number one, treatable. It's the most common mineral deficiency in the world, really, really common. And it's important that you know because there aren't gonna be symptoms. You're not gonna notice. My son was doing great. He was growing beautifully and he was happy and he was sleeping well. There was nothing going on that made us think his iron's gonna be low. So I was totally caught off guard, as are a lot of my patients. Now, here we go. Just a reminder: if you're borderline, not good enough. Now, if you're borderline or lower, what do we do? Because sometimes families will tell me, well, I'll just eat more iron-rich foods and I just want to do cast iron scalets, but I really don't want to do any supplements. I don't want to take any medicines. And I hear that. But please, this is where I say we really want to close this gap. And it's hard to absorb a lot of iron in our diet, especially if it's all at once or just kind of sporadic. It's kind of complicated. And I'm not going to get into all of the mechanics of iron absorption. Perhaps if that's something you're interested in, let me know. And I might do a podcast on it because it's really fascinating, but a little nerdy. And so what I like to communicate is that we get about 10% of what we eat actually absorbed, five to 10%, depending on other things in it. And the thing about babies and toddlers is that they don't usually get that much anyway. And they like to eat a lot of the foods that sometimes can interfere with iron absorption. Iron is best absorbed when it is in the heme source. So when it's like meat sources, specifically red meat and some seafoods. And then, and other like white meats have some too, but the red meats really are a little better. And then there's non-heme sources, which mean they're not from an animal source. These are things like our iron fortified grains and lentils and beans. Um, some of our vegetables even have some non-heme iron in them. And those really need to be paired with vitamin C to be well absorbed. They can be blocked by absorption when they have fiber added to them, or something called phytates, which are actually in, you know, a lot of nuts and seeds. So specifically, products like almond milk and things like that can actually interfere with iron absorption, even though it's been added to the product, for example. Um, and then there's also um, you know, things like tannins, which not a lot of kids are getting, but adults might be getting that are in your tea or in your drinks. And they can interfere as well as certain components in the pH, like calcium and zinc and magnesium. Some of these other components can interfere with iron absorption. And so, depending on what else is going on in the diet, it can make it really difficult for your baby to get the iron absorbed, even though they're getting it in their foods, which is why we sometimes need to overcome this gap with supplementation. And I don't love supplements. I, if you've listened to any of my other content, you know that I'm a food first, supplement second kind of girl. But this is a spot for supplementation. And I'm gonna say this like really clearly, because really and truly, if we recognize that there is a gap in our iron, we want to close that as fast as we can, as safely as we can, with as few side effects as we can. And so this sometimes takes multiple conversations with your pediatrician or healthcare team because it's not always achieved very easily. There's road bumps. Sometimes we forget to give it to the kid. Sometimes the kid doesn't like it, sometimes it gives him constipation. These are conversations worth having because you want to close this gap. It's not just a, well, if you feel like it kind of thing. It's a, we want to care about this brain and we want to care about this baby in this body that's growing because it really matters. And when we do that, it's a weight-based dosage. So we're typically doing that a little bit higher dosage, about three per kilo. The frustrating thing is that a lot of time on the boxes for iron supplements, which there's many out there, but they'll give you a recommended dose that's for maintenance, that's not for supplementation. So if you're in the camp where your kid needs to close a gap, like mine was, we want a real supplemental dose. We don't want to play around with just a drop. We want a real solid dose. So this brings me to point number three. And that is that we need to close the gap. If your kid is iron deficient, it's not just okay to give a little drop and not think about it anymore. We want to make sure, we want to retest and make sure that we have done the task, we've done the job, and it's fixed. Now, this is a little bit interesting because really, right now, the recommendation from AAP, this just came out in July of 2026 for pediatrics, a new update, and it's exciting and wonderful. And I'm really, really proud that the AP published this. So way to go. But in this recommendation, it's to do ferritin for screening if possible, which is a blood draw from the arm. And most kids are going to look at hemoglobin and make sure that's finished and close the gap. I think if you wanted to take this a step further and finish with a ferritin, it's not a bad idea, but it's worth a conversation to understand if it's, you know, how given how low your kid was and what your resources are for um ensuring that that's done. But really and truly, we're looking to make sure that that hemoglobin has normalized. The other reason I care about this is because a hemoglobin finger poke that we do, the one that I did in my office and that happened for my son, only catches about 25% of the kids who are actually iron deficient. So it's going to catch the kids at the bottom of the barrel, but there's a bunch of kids above that who might have low ferritin, but not have low hemoglobin. And so there's a case to be made for how do we really screen? The trouble is that we don't have a very good screening tool that's in the office, point of care, like we do for hemoglobin. Maybe in the future, but at the end of the day, we just want to make sure that our ferritin, um, when it is treated and we have a good threshold, that we are out of that low and borderline territory and up into that higher category. Now, I've talked a lot about hemoglobin and I didn't really tell you about ferritin levels. And this is relatively new. There are different lab values, and you'll actually see this um in differently in adult literature. But at this point in time, for little kids, we consider iron deficiency anything below 20. This is huge because you guys, when I was in training years ago, the number was way lower. Like, and most of our lab indices on our tools where I practice, it's around 10 and even eight, depending on what lab you're looking at, as considered normal. But we really want to see that ferritin be higher, all the way up to 20 for um little ones. And then it can it can be higher depending on where you go. Now, takeaway number five is that you can actually supplement your breastfed baby. I have a mama who is from another country where in their culture they actually do supplement breastfed babies as soon as four to six months when they're starting solids. And I thought that was kind of brilliant, you know. And she asked me, well, aren't we gonna start iron supplements? And I was like, oh, well, we don't do that in the US, but I think we probably could. And lo and behold, it's in the new recommendations. So this is hot off the press, brand new. And yes, you can supplement your exclusively breastfed baby with iron supplementation, but this is at a maintenance dose, not a really high dose. So we're talking more like one milligram per kilogram per day. So for most babies, they're somewhere in like the five to 10, more like seven to 10 kilo range at this stage. And that's where you can supplement with a little bit of iron supplement. And that's okay to do. However, um, then the next question becomes what if my baby is on formula? Do I need a supplement? No, because formula already has supplementation in it. We still want to screen our babies who have formula, but they aren't at as high risk as our breastfed babies. And this is the next question I often get of well, what should I be feeding them in the first, you know, solid foods? And for that, I would say go back and listen to episode 18 because I talk a lot about that. But I also really want you to know that I want you to feed them what you want to feed them and with good reason, but variety is key, not just one thing. I'm not gonna just recommend liver and bone marrow or something that you think is really high rich in iron. It's really about variety. We're building the palate. It's not the only thing we care about in this stage of life, it's just important in its timing. And so here's the next question I often get. Okay, well, I'm breastfeeding. What if I just take the iron for myself? Won't that like be enough for the baby? And the answer is no. I'm sorry to tell you, but you could have an amazing level of iron in your body, but your breast milk is still gonna have about the same amount, which means that your baby's still gonna potentially have a gap. And so, yes, I want you to take care of yourself. Yes, you should make sure you are not iron deficient for you, for your energy level, for your body and for your health. But being iron deficient or having enough iron isn't really going to change your iron in your breast milk. It's a pretty fixed and constant number either way. Now, the other thing I like families to know is that, and here's my last takeaway, okay? A common misconception that I think a lot of families can, you know, think is that protein and iron, they think of them in the same things. And they're not. So here's we're gonna get into a little bit of the practicals of the foods, okay? Protein is not the goal, okay? It's iron. Now, I think protein is great, but understand that babies in their growth needs actually need a lot of carbs and fat for growth. They need this for brain development. They need this for energy and for fat storages. They also really need this because these are the things that actually help them build tissue. Like I'm talking the literal inches that they're growing and the literal squishies in their legs. That comes from carbs and fat. Not a whole lot of protein. A little bit goes a long way. And they're very efficient with the protein that they get. The protein that they eat goes where it needs to go, does what it needs to do, and gets reorganized in the right ways. But it's not the same. Okay. So like iron and protein are not the same. Here's what I mean. There's a lot of foods out there, especially baby foods, even that now have protein added or are highlighting their protein. And that might be okay, but understand that our babies and toddlers, especially in America, are actually not protein deficient, even when they're iron deficient. These are very different things. Okay. Protein comes in lots of forms. It comes in our plant sources and our animal sources. And we use those. Those are amino acids. We use those, we break them down, we reorganize them and put them where they need to go. Very little protein is really needed at one. For example, a one-year-old, a standard one-year-old, really only needs about 11 grams of protein in a day, which they're going to get with 11 ounces of cow's milk. Done. You don't need any more. Are you going to get more? Yes. But that's not the issue. Okay. Iron is actually a mineral and it's a micro, it's in milligrams in food. So it is in our heme sources, like I mentioned, our animal sources, and it's also in our non-heme sources. Together, you need about 11 milligrams a day in our kids' four months to about a year. And then once you hit about a year, it goes down to about seven. So it comes down a little bit. But bear in mind that if your gas tank was partially empty or maybe a third of the way full at a year and your hemoglobin was okay and you continue to grow, but you have a further gap, you might actually create a gap later. So sometimes our two-year-olds are the ones that are iron deficient. And guess what? We screen there too. But I want you to understand that it's not protein that's going to prevent this. It's really, truly iron. And you can get that in some of our protein-rich foods, like meat specifically, but they're just not the same. And I really like to distinguish that because sometimes families think, okay, I'm going to get them to eat meat, or if they don't eat meat, they're going to be iron deficient. But then they eat a ton of Cheerios, which have actually a lot more iron in them. That's awesome. You know, the iron that comes in our non-heme sources, like our Cheerios and our prunes, are really great sources, even though they're less bioavailable. Sometimes we get enough of them to meet the need itself. So don't knock your Cheerios. Don't knock those fortified grains if that's your primary source or your beans. There's still value in them. Just understand that they do better when they're paired with vitamin C. And I'm going to do you a solid. At the end of this, if you go down to the show notes, I'm going to have a link in there for a freebie that I made that's iron and vitamin C foods. It has some categorized into your heme and your non-heme sources. And I'm happy to share it with you. So feel free to grab that if that's helpful and just to kind of think of some ideas. And usually what I tell my parents at four to six months, and then kind of on most of the visits, is babies do really well when they eat what you eat, when they get to see you and enjoy what you're doing at the table. So I would love for you, in an effort to prioritize getting iron-rich foods for your baby, I'd love for you guys to get really iron-rich foods in your diet. And in the bottom of my downloadable tool, it has some pears and some recipe ideas or things that you can do for yourself. For example, there's a spinach smoothie in there. And that is actually pretty delicious, has a lot of iron and vitamin C, pretty well absorbed. There's also like things like mashed potatoes and peas, because mashed potatoes, believe it or not, have some vitamin C. And carrots, on the other hand, have iron. Okay, so just to summarize here, number one, if you are worried about iron deficiency anemia, you're probably not the problem. It's not genetic. Number two, if you have borderline hemoglobin, it's worth treating. Don't sleep on it. Number three, if you are iron deficient, treat it all the way and prove that you've closed that gap and everything is solid. Number four, you can prevent some things potentially by supplementing your breastfed baby. Pretty cool. And lastly, protein and iron are not the same thing. So make sure you understand what's going to help your kid get there. Now, I hope this has been helpful. Again, this is all for educational purposes only. Talk with your doctor if you are in this camp and you need testing and treatment because it's important to make sure that your baby gets the right care. All right. So that is it. Thank you so much for listening all the way to the end. And let me know if you have questions, thoughts, ideas, because I gotta tell you, these conversations are so much fun. And I really hope that you feel empowered to understand your kids' hemoglobin and how to navigate low iron in your baby. Thanks so much for listening. We'll see you guys next week.