Breastfeeding a Toddler? Should You Be Concerned About Iron Deficiency?

You may have heard about a study published in Pediatrics last week (Maguire et al. 2013) showing an association between iron deficiency and breastfeeding beyond a year. If you’re breastfeeding a toddler, or considering it, you might be wondering if you should be worried about iron deficiency. There is very little research on breastfeeding beyond a year in developed countries, so this study is worth a closer look. (If you’re interested, I’ve written before about some of that research, my own reasons for choosing to breastfeed beyond a year, and my experience of weaning my two-year-old.)

What This Study Shows

This was a cross-sectional study of children ages 1-6 in Toronto, Canada. Blood samples were taken from 1647 children, and their mothers were asked, “How long has your child been breastfed?” We always have to be cautious about studies based on parental recall. However, research shows that mothers actually answer this question with good accuracy (Li et al. 2005). Of the children in this study, 93% had been breastfed at all, and median breastfeeding duration was 10 months. Twenty-seven percent of children were breastfed for more than one year, and 4% breastfed for more than two years.

The children’s blood samples were analyzed for serum ferritin and hemoglobin. Serum ferritin reflects the amount of iron stores available for use by the body, so it can be used to assess iron deficiency. If an iron deficient child also had low hemoglobin, he was diagnosed as having iron deficiency anemia. In this study, the prevalence of iron deficiency was about 9%, and 1.5% had iron deficiency anemia, findings similar to other studies in developed countries (Baker et al. 2010, full text here).

This study showed that kids that were breastfed for longer were more likely to be iron-deficient. Each month of breastfeeding beyond baby’s first birthday increased the risk of iron deficiency by about 5%. Children who were breastfed for longer than a year were estimated to have 1.7 times the odds of being iron deficient than those breastfed for less than a year. The researchers corrected for several potentially confounding factors: age, gender, birth weight, BMI, ethnicity, household income, day-care attendance, age of introduction of solids and cow’s milk, and current daily intake of cow’s milk. Children with iron deficiency were also more likely to be heavier at birth (bigger babies have higher iron requirements), younger (meaning that older kids seemed to have recovered from iron deficiency), and to be drinking more cow’s milk (something I wrote about here). Breastfeeding duration was not associated with iron deficiency anemia, which would indicate a more severe deficiency.

An obvious limitation to this study was that the observed relationship between breastfeeding and iron deficiency was just a correlation. There are other factors that could come into play that weren’t examined, like timing of umbilical cord clamping and how much iron these kids were getting from their diets or supplements. For example, it’s possible that moms who breastfeed longer are less likely to give their toddlers a multivitamin or other iron supplement. It that case, it wouldn’t be the breastfeeding that increased the risk of iron deficiency, but rather something else about moms who choose to breastfeed beyond a year. This is a major limitation, but to be fair, almost every study that shows positive outcomes for breastfeeding has the same problem.

Why be concerned about iron deficiency?

Iron is a mineral essential to life in all animals. Most of the iron in the body is used to make hemoglobin and myoglobin, so iron is really critical for oxygen transport to all tissues of the body. Iron is also part of several enzymes involved in energy metabolism. Every cell in the body requires iron, but blood, brain, and muscle cells are the ones that really suffer if there isn’t enough iron around. A person with severe iron deficiency will develop iron deficiency anemia, one of several types of anemia.

Iron deficiency in the first years of life, even without anemia, has been associated with cognitive, motor, and behavioral deficits (Lozoff et al. 2006). There are a lot of confounding variables in these studies, because kids that are iron deficient are likely to have other disadvantages as well. However, there are mechanisms for a causal relationship established through animal research (McCann and Ames 2007). So there’s some controversy as to just how scared we should be about iron deficiency, but given that we’re talking about brain development of our kids and that iron deficiency can be corrected with dietary changes, I think we should pay attention to it.

The current study was the first to look at the relationship between breastfeeding and iron in toddlers. Many studies have shown that exclusively breastfed babies are at higher risk for iron deficiency during late infancy (reviewed by Baker et al. 2010, full text here). Human breast milk is low in iron, but babies are usually born with enough iron, passed from mom via the placenta, to last for about the first six months. Delayed cord clamping at birth can extend the iron stores by another month or two. If breastfed babies aren’t getting some good iron-rich solid foods by late infancy, they can become iron-deficient.

So should I be worried about my breastfed toddler?

Worried? I wouldn’t go that far. Instead, I’d say you should be alert to the possibility that your breastfed toddler could become iron deficient. The good news is that it isn’t that hard to prevent iron deficiency if you’re mindful about nutrition.

How can I ensure that my breastfeeding toddler is getting enough iron?

Why would a breastfed toddler be at greater risk for iron deficiency? The study at hand doesn’t tell us, but I’ll speculate for you. Breast milk doesn’t have much iron. Yes, the iron in breast milk is well-absorbed, but there is still very little there. That’s probably a good thing for an infant (more on that here), but it means that breast milk really can’t provide complete nutrition for a growing toddler. Toddlers need good iron-rich sources of solid foods in their diets.  If a toddler fills up on breast milk, then it may be challenging for him to get balanced nutrition.

So how can you make breast milk part of a balanced diet for a toddler?

  • Talk with a health care provider about your child’s risk for iron deficiency. Consider having him tested so that you know if you should be concerned. If he does test low for iron, then depending on the severity, your pediatrician might recommend a supplement or suggest trying to correct the problem through diet.
  • Include lots of iron-rich foods in your toddler’s diet, like meats, legumes, whole grains, green veggies, and dried fruits. Of course, toddlers can be picky, so this may be easier said than done. Know that it may take many low-pressure exposures for your kid to be ready to try new foods. Iron-fortified breakfast cereals are a good option for more skeptical eaters. You can find a list of iron-rich foods, as well as strategies for increasing iron absorption, in this post.
  • Cow’s milk inhibits iron absorption. If your toddler is breastfeeding AND drinking cow’s milk, consider limiting cow’s milk to just one or two cups per day (or even none at all). Of course, without cow’s milk, you’re losing a good source of vitamin D (also low in breast milk), so you may want to consider a vitamin D supplement.
  • Evaluate if breastfeeding is getting in the way of your toddler eating well at meals. This might be an issue if you’re breastfeeding on demand throughout the day. Toddlers do better with eating if they have structure around their meals and snacks. To you and your toddler, breast milk is probably much more than a food. It is comfort, closeness, and a moment of quiet together. But, it is also calories, and there’s no getting around that. Toddlers who snack on breast milk throughout the day might not come to the table hungry and be ready to eat a variety of foods with the rest of the family. If that seems like it might be an issue for your child, consider fitting breastfeeding into times of day when it is unlikely to interfere with eating, such as before nap and bedtime.

If you’re breastfeeding beyond a year, what do you do to balance breast milk and foods in your toddler’s diet?

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13 thoughts on “Breastfeeding a Toddler? Should You Be Concerned About Iron Deficiency?

  1. My son is two tomorrow and we are still breastfeeding on demand. Lately I have been thinking about scheduling or limiting our nursing sessions, more for discretion in public and for my own sanity than anything. I realised I am allowing a lot of mindless reaction nursing when he is bored or fussy. The best solution is to get us both physically engaged in something else, which thankfully is a lot easier now that it’s warmer!

    Since I have definitely noticed an increase in eating at meals when I am more mindful about when, how much, or even if he snacks during the day, it follows that nursing would have an impact too. Since nursing is so much more than nutrition for us now I sometimes forget that he’s actually consuming something! The concepts laid out in the book “French Kids Eat Everything” have really resonated with me, and I’ve been trying to incorporate some of those higher expectations to our table, with very positive results. I am starting to wonder what else my son is capable of! Do we really have such low expectations for our children? It makes me wonder if the philosophy of “letting kids just be kids” all the time lends to a skewed sense of entitlement.

    • Hi, what did you learn from the “French Kids Eat everything” book? Thinking about getting it…thanks! Tara

    • Yes! I think that our kids often surprise us with what they are capable of when we set our expectations a bit higher! I see that in my own parenting all the time. I get nervous about a change or something and I find that if I confidently can say, “I know this is different, but we’re going to start doing things this way and here’s why…” it is usually well-received. I think so much of our expectations about meals (and nursing) come down to being able to convey them to our kids with respect and in a way that lets them know that they are part of this family, and we do things a certain way because we all want to be healthy, spend time together, and take care of each other.

      I know many people have strong feelings about setting limits around nursing toddlers. I think you have to do what you feel comfortable with, and if you explain your new expectations to your toddler, he may protest but he will adapt to it and might even appreciate the clear expectations. And I agree – it can become an issue if your toddler begins to associate nursing (or eating in general) with boredom.

  2. Alice, I’m still breastfeeding at 17 months. I give my son a daily iron supp (15 mg ferrous sulfate). I’m considering alternating the supplement with a dessicated liver supplement for its high iron content, but I’m unsure about giving my baby liver. Any thoughts on this? (Oh, and we currently live in a third-world country, so MD’s here are not exactly stellar…I’m trying to make the best decisions here with the resources I’ve got.). Thanks!! :)

    • Hi Tara – Well, I can’t take the place of a medical professional, but I can tell you what I think. Has your son been tested and found to be iron deficient? (Maybe that test isn’t available to you?) Are you able to fit some good dietary sources of iron into his diet? I ask because I think it is almost always preferable to get our nutrients from foods rather than supplements, unless you are trying to correct a frank deficiency or there are other reasons why this is hard to do with diet. I would be careful about using liver because it is certainly possible to get too MUCH iron – it can be toxic. The supplement industry is poorly regulated – sometimes they are not labeled correctly, so there may be more or less iron than you think in the liver supplement.

  3. My daughter is 10 months old. Right now she still nurses 4-5 times per day. Since she was about 8-9 months I try to keep nursing on a schedule (at 5am then back to sleep for 2 hours, 10am before am nap, before pm nap at 3ish and bedtime sometimes she gets a little when she wakes from a nap). This is so that she is hungry for food at meals too. I will be starting back to work (7am-1pm) when she is about 11 1/2 months old. I really hate the breast pump and I don’t want to start her on a bottle at 11 1/2 months so it looks like we will be weaning the nursing before her am nap. I will still nurse before work, at pm nap and bedtime and we will see what she wants to do. I have some milk in the freezer though so I think she can have it from a cup at lunch with grandma instead of cow’s milk. I think I will try to drop the nursing before the pm nap by Sept or Oct as well. I think it is important for her to be hungry for dinner and to eat real foods. I want her to nurse at in the morning and bedtime as long as she wants though. Since she nurses around 5 then goes back to sleep, she doesn’t eat breakfast until around 8 so. I don’t think it interferes much with her eating. Her meals and snacks are also at regular times.

    • I think your plan sounds like a natural progression of slowly letting more and more of her calories come from solids while still keeping your breastfeeding time together going. I breastfed Cee first thing in the morning until just the last month or two before we weaned (a few weeks about her second birthday – the before bed nursing was the last to go). I don’t think it interfered with her breakfast. Kids are often pretty hungry at breakfast, and the time it took for us to get going and get food on the table was enough of a break that she still came to the table hungry.

  4. Great information! Thank you as always for your knowledgeable and timely post.

    We continue to do “scheduled” (EAS) breast feedings at 22mos. He refuses BF without reading books at the same time, but will BF for 40+ minutes when books are involved (down from 90+ min just 3mos ago). I was more careful about iron between 9mos and 1yr. He ate an egg every day and some weeks I instead gave him some chicken liver. Now I’m not as careful. Although he’s gone through stages, I’ve followed the food introduction ideas from Karen Le Billon’s blog, the book Bringing Up Bebe by Pamela Druckerman, and other places that say to work on the palate first and continue to offer foods that they have refused before. I usually try different textures until I find one he will accept. He now eats a huge variety of foods but I often wonder if he is getting enough iron, calcium, and fat. We will be getting the iron checked at our 2yr visit to see if low iron could be the cause of some night wakings. I was told by a nurse who specializes in sleep that Ferritin levels under 50 can effect night wakings in toddlers and children. She also theorized that it was more common at the higher altitude of Denver.

    We do try to pair iron rich foods with vit C for better absorption and limit cows milk and cheese in those same meals. We only eat red meat about once a month. I’m not sure how to make sure we get enough calcium without cows milk and cheese. Although he eats a few leaves, they are not a favorite and the green smoothie fascination only lasted a couple weeks.

    • Another good source of calcium is dried beans – and they’re also a good source of iron! If your son is eating a variety of foods, he’s probably doing OK nutritionally, but it doesn’t hurt to check.

  5. I have a question that is somewhat unrelated to the post, but related to the end of it. You mention that toddlers do best with structure around their meals. I am wondering what strategies there are for making a transition from early nursing on demand to structured meals in toddlerhood. My almost 14 month old recently completed weaning, but she seems to want to graze the same way she did when she was a nursing newborn eating every hour to two hours. I would like her to have something of an eating schedule, but I don’t want to deal with a miserable, cranky, perhaps hungry toddler all day either. How do I get there? A couple of days of cranky are OK, but every time I have tried to impose some sort of schedule I get a lot more than a couple of days of cranky.

    • Hi KT – I think this transition from on-demand to structured feeding often takes parents off-guard. I remember struggling with this as well. I recommend setting up a predictable routine with 3 sit-down meals plus sit-down morning and afternoon snacks. Make each one balanced for nutrition – snacks should be essentially mini-meals. At this age especially, be sure to have a good source of fat at each snack so that she can fill up on that. With this kind of schedule, you’ll only have 2-3 hours between each eating time. Let your child know that this is the plan, and be very consistent in the rule that we only eat at the table, sitting down. Then, for at least the first few days, plan some fun things to do that will make the time pass quickly. Get out of the house, and don’t bring a snack with you. If your toddler asks for a snack, remind her that you’ll have a snack or meal soon at home, and you’ll eat it at the table. Let her know that she can count on that. She may be cranky for a few days as she gets used to stretching out times between eating, but toddlers can absolutely handle this. It is good for them to develop a little patience around eating and then to come to the table ready to eat a variety of foods. And once you have the structure, you can lighten up on some of the rules too. For example, we often have Cee’s afternoon nap in the car or the stroller, because we need to run errands or I want to fit in a trip to the park between nap and dinner. I know this isn’t ideal, but it still isn’t “on demand” – it’s a snack at our regular time with a somewhat relaxed structure. Hope this helps!

  6. I’m a dietitian and mother of a 1yo boy. Out of curiosity I’ve been “experimenting” with my son’s diet, analyzing its’ nutrients and unofficially supporting other mothers in their nutritional concerns. As Alice pointed out, recalls and parental observations have their flaws but are usually attempted to compensate by oversampling. At any rate, it’s true that the correlation doesn’t address cause-and-effect. Many BF moms I encountered use it as a safety net and not progressing the toddlers’ diet, or told me they think breastmilk is the best food forever. The government recommended level is 7mg of iron per day for 12-36mo toddlers. But with an egg providing 0.8mg, 3oz chicken roughy 2.5mg, and 3oz beef about 3.8mg, how can my son eat 7mg each day? He used to eat organic chicken liver in puree but wouldn’t eat it as finger food now. Dietary iron has very little chances of causing toxicity as the body knows how to handle it unless there’s a metabolic error. Supplements on the other hand is not ideal for many reasons. I’m still trying to wrap my head around this. My son eats good amounts but he’s far from that amount of iron even including plant sources. And if I may, I don’t believe cow’s milk per se interferes with iron absorption, it’s the calcium that competes. So yes, all milk, yogurt, and significant calcium intake within a couple of hours of iron intake. However, I usually suggest to mothers not to stress out if there’s no perfect time of the day for an empty stomach. And while vitamin C enhances absorption, juices are not necessary, a bite of fruit will do just fine with less sugar.

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