Anaemia and Iron Deficiency in Babies and Children: Signs, Causes, Foods

Your 18-month-old daughter drinks three big glasses of milk a day, picks at her plate and looks paler than her cousins. The paediatrician mentions anaemia and orders a blood test. This is a common situation: iron deficiency is the most frequent nutritional cause of anaemia in young children, according to the World Health Organization.

The good news is that it can largely be prevented on the plate, with foods that Moroccan cooking knows well. Here is how to spot it, why it happens and what really helps.

What is iron deficiency anaemia?

It is a shortage of red blood cells or of haemoglobin, the protein that carries oxygen in the blood. To make this haemoglobin, the body needs iron. The Canadian Paediatric Society also reminds us that iron plays a part in normal brain development: that is what makes deficiency important in a toddler, even before full-blown anaemia.

The phenomenon is massive. The WHO estimates that about 40% of children aged 6 to 59 months worldwide are anaemic. In Morocco, a study published in 2010 by the WHO's Eastern Mediterranean journal cited a national survey from 2000 that found 31.5% anaemia in under-5s. These figures are old and more recent data are lacking, but they show the subject is far from rare.

Not all anaemia comes from a lack of iron. Some inherited red blood cell diseases, such as thalassaemias or G6PD deficiency (favism), are also responsible. That is another reason why we should never treat "blindly".

Why do babies run short of iron?

A baby born at term arrives with an iron reserve built up during pregnancy. According to the Canadian Paediatric Society, breast milk is then enough until about 6 months. After that, the stores run out and food has to take over. That is why the period from 6 to 24 months is the riskiest.

Situations that increase this risk, according to Canadian sources and the Mayo Clinic:

• A premature birth or a low birth weight: the stores are lower from the start.
• Starting solids too late or with few iron-rich foods after 6 months.
• Cow's or goat's milk as a drink before age 1.
• Too much milk after age 1: the child fills their stomach with milk and eats less of everything else.
• A very restricted diet, a very picky child or a poorly organised meat-free diet.
• Repeated infections or intestinal worms, which the WHO lists among the causes of anaemia.

The WHO adds a point that is decided at birth: waiting at least one minute before clamping the cord helps build the baby's stores. It is a question to ask at the maternity ward.

Cow's milk and tea: the two traps of Moroccan tables

Cow's milk contains almost as much iron as breast milk, but the body absorbs it poorly. The Canadian Paediatric Society therefore recommends not offering it as a drink before 9 to 12 months, then not going over 500 ml a day after age 1. The Mayo Clinic sets a slightly higher limit, around 710 ml a day between 1 and 5 years. The figures differ, the idea is the same: milk must not replace meals. It is all detailed in our article on cow's milk for babies.

Tea is the other trap. The Canadian documents remind us that it hinders iron absorption. In Morocco, the glass of atay (mint tea) offered to a child at snack time or after the tagine is an affectionate gesture. But for a toddler, water at the table is better, and no tea at all, especially as it is often very sweet.

What are the signs of iron deficiency?

The signs are subtle and appear slowly. Many parents only notice them with hindsight. The Canadian Paediatric Society and the Mayo Clinic describe:

• paleness of the lips, the inside of the eyelids, the palms or the nail beds;
• tiredness, a less active, irritable child;
• lack of appetite;
• slower weight gain, visible on the growth chart;
• breathlessness on effort, cold hands and feet;
• in older children, difficulty concentrating;
• sometimes, a craving to eat soil, ice or other non-food things.

None of these signs is enough to make the diagnosis. A blood test is needed.

How is screening done?

By a simple blood test: a full blood count measures haemoglobin, and a ferritin measurement tells about iron stores. The doctor interprets the results according to age.

Countries do not all make the same choice. In the United States, the American Academy of Pediatrics recommends a check for all infants between 9 and 12 months. In Canada, routine screening is not considered useful for everyone, but is considered between 6 and 12 months for children at risk. In Morocco, bring it up at a follow-up visit, especially if your child was born prematurely, eats little meat or drinks a lot of milk.

Which iron-rich foods should I give my child?

Iron in food comes in two forms. Iron from meat and fish is the best absorbed. Iron from plants is absorbed less well, but becomes more effective when served with a vitamin C-rich food.

In practice, a purée of well-cooked lentils with a touch of tomato, a beef tagine with peas where you mash the meat with a fork, or orange segments for dessert after a chickpea dish: these are simple meals, within reach of every family. To adapt dishes without salt or strong spices, see how to cook Moroccan food for baby. A cooking blender helps get fine textures for the youngest, but a fork and a saucepan do the job very well.

One caution: if your child has G6PD deficiency, fava beans must be left out of all these recipes, raw or cooked.

Should I give an iron supplement?

Only on medical advice. The Canadian Paediatric Society explains that most babies born at term do not need one, while the American Academy of Pediatrics, cited by the Mayo Clinic, suggests a supplement for exclusively breastfed babies from 4 months. Premature and low-birth-weight babies often receive one earlier. These differences explain why the choice is made case by case, with the paediatrician.

If anaemia is confirmed, the doctor sets the product, the dose and the duration, often several months, then checks the result with a new blood test. Stools then turn dark, which is normal. Never give iron "to build them up" without tests: the anaemia may have another cause, and an overdose in a young child can be fatal, the NHS reminds us.