Iron deficiency is the most common nutritional deficiency in children in the United States. Its prevalence in infants younger than 1 year of age has decreased owing to improved nutrition; however, iron deficiency in toddlers remains a significant problem. Excessive consumption of cow’s milk and other iron-poor foods can lead to iron deficiency. Iron deficiency, in turn, can lead to remarkable anemia and to long-term cognitive deficits. Therefore, in toddlers with dramatic anemia, the excessive ingestion of cow’s milk is a consideration.

Iron is necessary for hemoglobin production, which is required for oxygen transport. Healthy term infants are born with enough iron stores to last about 6 to 9 months. Dietary iron is required for growth and to replace daily iron losses. Inadequate dietary intake and poor absorption of iron contribute to iron deficiency.

The American Academy of Pediatrics (AAP) recommends that infants younger than 1 year of age consume breast milk or iron-fortified cow’s milk formula. Breast milk contains less iron than does iron-fortified formula, yet it is better absorbed. Between 4 and 6 months of age, infants require an additional source of iron, such as an iron-fortified cereal. After 1 year of age, children should consume 16 oz/day of vitamin D-fortified whole milk and a variety of healthy table foods.

Risk factors for iron deficiency include early introduction of cow’s milk at younger than 1 year of age and consumption of >24 oz/day of cow’s milk. Cow’s milk contains very little iron and often replaces foods that are rich in iron. In addition, cow’s milk inhibits iron absorption from other food sources and can cause occult intestinal bleeding.