Why does my child fall sick so often?

We are not going to give you immunity building tips. The answer lies here. Iron deficiency. Low hemoglobin has troubled our children for years together, without realizing its impact.

Well, if you think what we are talking is wrong, talk to any pediatrician or see the stats:

INDIAN STATISTICS: About 70% of Indian children under the age of 5 yrs are estimated to be iron deficient; that is a whopping 89 million children. Amongst adolescent girls, its around 40%.

Worldwide statistics: Among children in the developing world, iron is the most common single-nutrient deficiency.In developed nations, despite a demonstrable decline in prevalence, IDA remains a common cause of anemia in young children and approximately 40% are iron deficient.

And, no its not a problem of under-developed societies or under-nourished children. Its found across all strata of society.

So, what does anemia have to do with recurrent infections?

Anemia is due to deficiency of iron in the body. Iron is a micronutrient, which forms a part of hemoglobin in the red blood cell. Hemoglobin serves as the oxygen carrying cell in the blood, means iron is required to carry oxygen anywhere in the body. So, iron supplies energy for all important functions of the body, whether it be muscle function, energy creation or brain development. A deficiency of iron, iron deficiency (ID) leaves the child vulnerable to a lot of problems, including recurrent infections, easy fatiguability and long term side effects on brain. Some of these problems don't revert back to normal even after the hemoglobin level becomes normal.

How does IDA affect a child’s brain?

Long-term studies have shown that IDA in infants affect cognitive, language and motor domains, altering developmental trajectory and resulting in lower I.Q. at a later age. Older kids may have poor concentration in studies,poor memory retention, poor processing of information and even behavioural changes.

WHO ARE SUSCEPTIBLE?

• Our growing brains i.e. infants and toddlers

• Premature/Low birth weight babies

• Adolescent girls, who menstruate

• Children with health problems like chronic infections, food allergies

BUT I GIVE MY CHILD EVERYTHING TO EAT. THEN WHY IS THE INCIDENCE SO HIGH?

The answer lies in our faulty dietary practices

• Over dependence on milk: Our children are bought up with the concept that “My child has to have milk”. Milk and dairy products have insufficient absorbable iron. Additionally, parents tend to give in to the fussy eater by saying “He doesn't eat anything. With milk, atleast something is going inside the tummy”. What parents don't realise that in that process, they are killing a meal. Children between age group 1 to 5 who drink more than 24 ounces (710 ml) of cow's milka day are at risk for iron deficiency. Better not to go overboard with our milk obsession.

• Faulty weaning practices: The common foods which an average child in India has between 6 months to 1 year of age are mother’s milk, cow’s milk, biscuits, some liquids like dal water, rice water and fortified infant food products etc. Complimentary food has to be much more than that. Ideally a child should be eating from your plate everything (including all food groups) apart from spicy foods and animal protein by 12 months of age. So, take out time, plan well and let your child have nutrient dense semisolids and solids prepared freshly at home.

• Babies who drink cow's milk or goat's milk before age 1yr: Iron in cows milk is not well assimilated in the body and cow’s milk may even cause intestinal bleeding leading to further loss of iron from the body. All standard infant nutrition guidelines advocate avoiding intake of animal milk till one year of age.

• Giving Babies formula that isn't fortified with iron is again a common mistake.Common dairy products like milk powders,etc meant for general use are not advisable for infants .They are not manufactured as per the recommended requirements of the growing infant.

To top it up, worm infestations is quite prevalent in our society (28-50% in toddlers and school-going. children).

The hookworms (thin, white worms) which enter the body through bare feet are notorious for causing blood loss through intestines and iron deficiency anemia. Children with worm infestations typically complain of itching around the anal area. Another common misconception is worms are caused by eating sweet things which is completely wrong. Worms spread through unhygienic practices.

HOW TO DETECT?

After clinical evaluation, your pediatrician may ask for blood tests like:

• Hb concentration

• Complete blood count(CBC)

• RBC indices

Important note: The hemoglobin may be within the normal range in the early stages of IDA. Confirmation may further require specialised tests like reticulocyte concentration, total iron-binding capacity, transferrin saturation, zinc protoporphyrin, S.Ferritinconcentration and serum transferrin receptor 1 (TfR1) concentration.

HOW TO PREVENT AND TREAT IDA?

• Dietary modifications.

• Iron Supplements/tonics.

• Treat your child’s worm problem every 6 months.

All the three are required. Don't expect only diet to help when your child is highly deficient in iron.

0-6 months:

A) Full-term infants

• Mother should continue her own iron supplementation as per her doctor’s advice

• Iron supplementation at age 4-6 months as per your pediatricians clinical discretion until your baby is eating two or more servings a day of iron-rich foods.

If you breast-feed and give your baby fortified formula and majority of your baby's feedings are from formula, there is no need for the supplement.

B) Premature infants: Pediatricians would advise you to give your baby an iron supplement at age 2-4 weeks till your child’s first birthday. If you breast-feed and give your baby preterm fortified formula and the majority of your baby's feedings are from formula, again there is no need to supplement.

6 months -1 year:

Begin iron rich complementary semisolid /soft solids such as iron-fortified baby cereal, pureed beans, pureed leafy vegetables like spinach, RAGI (millet), porridge, jaggery. For older children, good sources of iron include meat, chicken, fish, beans and red meats, dark poultry, egg yolks, dry fruits like figs, dates, prunes and raisins.

BEYOND 1 year:

Most of the children this age are fussy eaters and all moms would agree that getting them to eat healthy foods like veggies is a big challenge.

Some tips:

A) Include Iron rich foods in the diet:

FOR VEGETARIANS

Dark Green Veggies:

• Spinach (palak): most versatile food used as a soup OR added to flour to make parathas OR added to potatoes to make cutlets or burger patties or stuffings for sandwiches OR pureed to add to pasta sauces (green pasta) OR added to dals OR gravies like palak paneer

• Fenugreek(methi) can be combined with dals or peas/paneer

• Amaranth(cholai/maath) can be used in soups or parathas

• Broccoli: easily available locally, soups or grilled, added to pastas, pizzas or cutlets.

• Mustard leaves(sarson) usually sarson ka saag tastes lovely with small rotis

FOR NON-VEGETARIANS

The body absorbs two to three times more iron from animal sources than from plants. Some of the best dietary sources of iron areheme iron found in red meat and liver. Soups, mince, cutlets, steamed fish all are great options for children. Eggs in any form make a good healthy option at any meal.

B) Fortified cereals are also an option as a breakfast or evening snack.

C) Vitamin C promotes the absorption of dietary iron. You can help your child absorb iron by offering foods rich in vitamin Csuch as citrus fruits, strawberries, tomatoes, amla candyanddark green vegetables. Combining iron rich plus vitamin C rich foods in the same meal greatly enhances uptake of iron in the gut, common examples are spinach with lemon, spinach with meat, bean salad with tomatoes, bell peppers with beans etc.

D) Try cooking food in a castiron pan, which can help enrich the food with iron.

E) Avoid excessive milk intake: Between ages 1 and 5, do not allow your child to drink more than 24 ounces (710 ml) of milk a day.

Note on Iron Supplements:

• Get a prescription from your pediatrician as dose depends on weight and the severity of deficiency; don't take medicines on your own

• Can cause black discolouration of stools; Don't stop the medicines.

• Teeth discolouration; but this temporary. Don't stop medicines and ensure that your child’s rinses the mouth after medicine. Also your child’s teeth will normalise once iron medicines are stopped.

• Constipation and sometimes diarrhoea. Do not stop treatment by yourself. Usually this is temporary and the body adapts over a period of time. Try to ensure enough intake of water, veggies, fibre, fruits like banana. If persistent, ,consult your doctor to change the type of iron supplement

• Metallic after-taste making it difficult for the child to take medicines. Give the medicine after food.

• Don’t give it with other medicines like calcium, antacids, laxatives, etc. This leads to drug interactions and inadequate absorption of iron. Always keep an interval of two-three hours between these medications.

• Do not give along with milk

• It may take 3-6 months to build up hemoglobin and replenishing of iron stores. So do not stop treatment once the child feels better, which may happen in a few weeks of starting iron

• Excessive and unwarranted use of iron or overdose may cause toxicity, so be careful

Should I have my child screened for iron deficiency?

Iron deficiency and iron deficiency anemia are typically diagnosed through blood tests. The American Academy of Pediatrics recommends that all infants be tested for iron deficiency anemia starting between ages 9 months and 12 months and, for those who have risk factors for iron deficiency, again at later ages.

So, next time before buying some immunity building medicine, check whether your child is iron deficient.

Disclaimer : "This handout is made on standard medical guidelines and is purely informative. Not to be used for treatment. The handout is IP of TPN. Any commercial use or misuse by third party will invite legal action"

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TPN Team

This article has been written by core team of pediatricians of The Pediatric Network which keeps parents updated on current issues relevant to children. The articles are thoroughly researched, reviewed and updated as per the latest information available.

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