Low Iron Level Baby Boot Camp
Disclaimer: This is not a sponsored post. The information contained within this post is not intended to replace health recommendations from your primary care provider. Low hemoglobin levels from a device such as the one featured in this post should always be followed up with a venous lab test to confirm the results.
What do you do if your baby’s iron levels come back low? Here’s a rundown of my daughter Hannah’s course with low iron levels at her 12-month pediatrician well-check, why I declined supplemental iron drops and how we used food to help bump her hemoglobin level back up.
In Office Iron Checks for Babies
Every pediatrician’s office is different - but most doctors will do an iron check (or anemia screen) in office at one of your baby’s routinely scheduled well-checks or if they suspect iron deficiency. The American Academy of Pediatrics (AAP) recommends screening for all infants at 9-12 months.
Because we have done baby-led weaning with 6 of our 7 children, I am particularly interested in iron level checks at the pediatricians. Even though my babies were not identified as being at high risk for iron deficiency anemia (IDA), I still ask for an in-office iron check at 9, 12, 15 and 18 month well checks.
Twelve percent of infants age 6-11 months have inadequate iron intake. Eight percent of toddlers have iron deficiency. I don’t want to start weaning foods at 6 months and then find out at 12 months my baby’s iron levels are low. That’s why I ask my doctor to do an in-office heelstick and hemoglobin check.
Checking baby’s hemoglobin takes 1 minute, it is not painful to the baby and it is not costly to the office to do so. Not all offices have the capability to do in-office checks so they may have to send blood out. The machine my office uses is called the HemoCue Hb201+ and it costs about $1,000.
It is important to note that the United States Preventive Services Task Force (USPSTF) and guidelines in Canada and the United Kingdom do not recommend universal laboratory screening for IDA in young children, citing lack of direct evidence of the benefits or the harms of this approach.
Hannah’s Low Iron and What She Ate After
Gus and Hannah are my twins and the 6th and 7th children in our family. They were born at 38 weeks, started solid foods with baby-led weaning at 6 months + 2 weeks and have no other health concerns or problems.
For ideas about easy BLW foods to start with, grab my free download “10 EASY STARTER FOODS FOR BLW”.
9-Month Borderline Low Hemoglobin
At Gus and Hannah’s 9-month routine well-check, Hannah’s hemoglobin level came back borderline low at 10.9 g/dL. Some resources say normal Hgb 9.5-13 g/dL (95 to 130 g/L), but my pediatrician likes to see at or above 11.0 g/dL. This is consistent with the World Health Organization (WHO) hemoglobin thresholds to define anemia for infants 6 months to children less than 5 years.
So, for hemoglobin - 11.0 g/dL is our goal to be at or above. At 9 months and 10.9, Hannah was just below that. (Her twin brother Gus never had issues with low iron, but I’ll document his hemoglobin levels at each check in this post too for reference. At 9 months Gus’ Hgb was 11.6 g/dL)
At 9 months Hannah was eating solid foods 2-3 times per day and had about 24 oz per day of half breastmilk-half formula (formula is iron fortified). I was offering at least 1mg iron food, preferably from animal source at each feeding (2-3 times per day).
For more information about what iron is, how much iron your baby needs, where do you get iron in the diet and how to increase iron absorption, read my blog post “3 Easy Ways to Boost Baby’s Iron Absorption”.
12-Month Low Hemoglobin
At Gus and Hannah’s 12-month routine well-check, Hannah’s hemoglobin level came back at 9.4 g/dL. I asked for a re-draw and to re-check it in office.
With previous babies I have had instances of low hemoglobin reading, ask for a redraw, they squeeze a little more blood and the second reading came back within normal limits. If I hadn’t asked for a re-draw I would have left the office feeling like my baby’s iron level is low. So in this case, when Hannah’s hemoglobin came back low at 9.4 g/dL. I asked for a redraw. The second reading came back at 9.4 g/dL.
I felt terrible. What was I doing wrong?
Was I feeding her the wrong foods? No. I knew that wasn’t the case.
At 12 months Hannah was eating solid food 3 meals per day. I was including at least 1mg iron from animal foods at every meal, fortified foods like pasta, plant sources of iron along with vitamin C to enhance iron absorption.
Was it because we stopped iron-fortified formula? No. That wasn’t it either.
We had switched to cow’s milk on her 1st birthday (March 7, 2019) but no more than 16 oz per day (too much milk can increase anemia risk as it displaces other iron containing foods). Her actual 12-month check was March 20, 2019 - so about 2 weeks after making the switch from half-breastmilk/half-formula to cow’s milk. But the halflife of hemoglobin is 120 days, so the low hemoglobin levels could not be attributed to the loss of iron-fortified formula so recently in her diet.
What was I supposed to do? Our pediatrician recommend iron drops and then scheduled Hannah to return in one month to have iron re-checked (at 13 months of age). We decided not do to the iron drops and instead to focus on increasing iron from food over the next month.
I have a very good relationship with my pediatrician and we had a talk about my decision not to do iron drops. My primary concern was constipation from supplemental iron. As many babies do with the transition to solid foods, Hannah had some degree of constipation and I did not want to exacerbate that with iron drops. I did not want the drops to possibly cause more constipation, resulting in decreased food intake and making the whole iron intake situation worse.
Furthermore, as a Registered Dietitian who teaches infant feeding and baby-led weaning for my job, I wanted to ensure that I could “fix” Hannah’s iron with food if I am recommending a food-first philosophy to my students and followers. Please note Hannah was not at high risk for IDA. She was not malnourished, did not have low birthweight, did not have dietary risk factors or other symptoms of IDA. Given my professional background and expertise in nutrition, I felt confident that foregoing iron drops for one month and trying food instead would not cause undue harm.
So we went home and I put together a one-month baby boot camp meal plan for iron.
High Iron Baby Boot Camp
For the next month we focused on iron in foods for Hannah in an effort to get her iron levels up. Again, the halflife of hemoglobin is 120 days, so one month probably wasn’t going to make all of the difference. Furthermore, there’s the reality that point-of-care measurements of hemoglobin - such as the one used in the pediatrician office - have only fair accuracy in identifying IDA (positive predictive value 10-40% at 12 months of age).
So I didn’t want to hang too much importance on two back-to-back in-office low hemoglobin readings at her 12 month check.
But it wasn’t a bad idea to double down on iron intake and iron absorption. Here are some of the things we did with Hannah over that next month:
Served high iron foods first - as a specialist in BLW, I don’t usually recommend dripping food. Dripping is putting one food or part of the meal out first, waiting until baby eats and then offering more food. I normally portion and plate the whole meal, serve to baby, allow baby to self-feed. This helps baby learn to pace, regulate and respond to hunger and fullness cues. But I did know that Hannah would always choose carbs and then fruit or vegetable and finally meat first. So we started just serving her meat first, waiting until she ate it and then offering the remainder of the foods
Serving an animal food at every meal - we eat some, but not a ton of meat in our family. The iron in animal foods is more well absorbed by the body than plant food iron is. I made an effort to offer at least 1mg iron from animal foods at every meal. Our family eats the same foods as the babies, so for this particular month I made meat more often: chili, meatballs, meat lasagna, kofta, slow cooker pork and lamb, dark meat chicken (more iron in dark meats) and lots and lots of egg yolks.
Serving a vitamin C food at every meal - vitamin C helps the body absorb iron from other sources. At every meal we had at least one fruit or vegetable. Fruits and vegetables contain vitamin C. Some are higher than others - citrus, tomatoes, strawberries, potatoes and bell peppers are among the highest.
Minimizing milk - At 12 months of age Hannah was drinking about 15-16 oz full fat (whole milk) cow’s milk out of an open cup. We use the Tiny Cup from ezpzfun.com (10% off with code KATIE10). That cup is 2 oz. After each meal, I would fill her cup up with milk 2-3 times, 3 times a day for around 15-16 oz total milk. I only offered milk after meals so she would eat food first. Babies who are full of milk are less inclined to eat food at mealtime.
13-Month Hemoglobin Re-Check
One month after her 12-month low hemoglobin reading of 9.4 g/dL, I brought Hannah back to the pediatrician’s office for a re-check. The goal was to have her hemoglobin back up above 11.0 g/dL. The reading at this 13-month recheck was 11.8 g/dL.
I did feel a sense of relief that she wasn’t low two months in a row. I can’t entirely attribute her “normal” values to one month of dietary intervention. However, I was happy that our efforts at home with iron and vitamin C foods seemed to have had a positive impact and that foregoing the iron drops recommendation was not harmful to Hannah.
15 and 18-Month Hemoglobin Checks
Because of Hannah’s history with low hemoglobin, I am always still aware of her iron foods intake and interested in hemoglobin checks at the pediatrician. I ask for an iron check at every appointment - and I’m sure that could be perceived as overkill, but considering what I do for a living as a dietitian specializing in infant feeding, our staff always obliges me. They also always give me permission to take the videos that I used in this post.
The goal for hemoglobin in babies 6 months up until childhood age 5 is 11.0 g/dL or higher. At Hannah’s 15 month check-up her hemoglobin was 12.0 g/dL. At her 18 month check-up her hemoglobin was 11.4 g/dL.
Here is a table of both Gus & Hannah’s hemoglobin values at their 9, 12, 15 and 18 month routine wellchecks. Hannah has a 13 month check because of her low value at the 12 month check.
Does BLW Lead to Low Iron Levels?
Babies should have iron containing foods in their diet starting at 6 months of age. This is because the iron your baby gets from mom at the tail end of pregnancy starts to dip at about this time.
When it comes to baby’s iron intake, keep in mind that no matter what feeding approach you choose, if it doesn’t contain iron your baby could be at risk for iron deficiency or anemia.
With traditional spoon-feeding babies often eat iron-fortified rice cereal. With baby-led weaning, although fortified foods aren’t typically used as often, you can still offer baby food that contains iron. Any diet can be deficient in iron if iron-containing foods are not included. There is no research to support the idea that baby-led weaning babies have lower iron levels than traditionally spoon-fed babies.
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Everyone on this free workshop gets a copy of my list of 100 FOODS TO FEED YOUR BABY...just for being there! Plus inside of the workshop I explain my 100 First Foods framework that lays out exactly how you can get your baby to try these 100 foods using baby-led weaning, and all before his or her first birthday. Stick around to the end of the workshop too where I host a Q&A to answer all of your burning BLW questions. Click here to sign up for the free workshop today
Additional Info about Anemia Screening
This is a follow up added to the post on Oct 30, 2019 - I received a good deal of helpful feedback from other healthcare professionals who read this post and wanted to comment or add info. Janet, MS, RDN who works as a WIC Nutritionist in Oregon shared that in her training on the Hemocue they have been taught to do it in a toe or finger and always wipe at least the first 2 drops and then collect the 3rd or 4th drop in order to get an accurate reading.
Another reader Martha, MS, RDN, CLC, CCHC who is also a certified blood anemia screener shared that it’s important for parents to know that the hemocue is simply used for screening and never to diagnose. She adds that low hgb levels should always be followed up with a venous lab test to confirm the results.
Thank you for this valuable feedback and I hope these additional comments help clarify some of the information in this post.
