It is very important for growing infants to get enough iron in their diet. Infants between one and two years of age who have iron deficiency anemia have been found to have lower scores on mental and motor functioning tests; their scores are also lower at five years of age. The late Frank Oski, who was a professor at John Hopkins School of Medicine and was one of the country's leading pediatric hematologists, summarized the importance of preventing iron deficiency anemia: "Three studies...have now suggested that iron deficiency anemia occurring at an apparently crucial time in infancy results in irreparable cognitive damage. Attention must be directed to prevention of iron deficiency. Breastfeeding followed by the use of iron-fortified formulas until one year can achieve this desired goal."

An active, menstruating woman should eat at least eighteen milligrams of iron daily. This is easier advised than done. A well-balanced diet supplies around six milligrams of iron for every thousand calories. Yet, women usually eat about 2,000 calories, which amounts to around twelve milligrams of iron a day. Add to this diminished iron intake the fact that women eat more fruits and vegetables (which contain poorly absorbed iron) and are generally not big meat eaters. This is why many women are anemic or borderline anemic without even knowing it. It would be wise for women to have not only a hemoglobin level done yearly, but also a serum ferritin test to check their total iron stores.

If you suspect anemia, look for these signs:
Paleness (especially noticeable in the face and earlobes of infants and children; in the palms and nail beds of adults)

• Weakness
• Fatigue
• Shortness of breath
• Irritability
• Difficulty concentrating
• Increased susceptibility to infections
• Intolerance of cold temperatures
• Constipation
• Brittle, flat, thin fingernails

"Borderline" anemia can usually be corrected just by increasing your dietary supply of iron, without taking iron supplements. If your child is anemic, here's how to restock the iron deficient body stores and elevate the hemoglobin level to normal:

Step 1: Using diet to correct anemia in infants requires about one milligram of dietary iron per pound per day. So a twenty-pound infant would need a minimum of 20 milligrams of iron per day, or about twice the usual RDA. Depending on your infant's willingness to eat a lot of iron-rich foods, it can be difficult to correct anemia with dietary measures alone. The good news is that the intestines compensate for iron deficiency by increasing the percentage of iron absorbed from foods, and you can improve iron absorption by combining good iron sources with vitamin C sources. It usually requires even more dietary iron than the above amount to correct anemia, but if your infant is only slightly anemic, it is worth trying the dietary increase for a couple of weeks, and then having your doctor recheck baby's hemoglobin.

Step 2: If dietary iron does not produce a significant improvement in your infant's hemoglobin and/or serum ferritin, it would be wise to begin giving your child iron supplements in the form of drops or pills in the dosage and timing recommended by your doctor. The usual oral dose is two milligrams per pound given three times a day between meals to enhance absorption. The iron syrup that is usually recommended for children is ferrous sulfate or ferrous succinate. During the first three weeks of treatment the hemoglobin increases at a rate of 0.15 to 0.25 grams per day, so if your infant has a hemoglobin of nine and it should be eleven, expect it to take around three weeks to reach this level. In order to replenish the depleted iron stores, it's best to continue oral iron supplements for at least two months after the hemoglobin becomes normal.

Step 3: If your baby's hemoglobin is not increasing by at least one gram after two to four weeks of treatment, your doctor may either want to increase the dosage of iron supplement or do some further blood tests to determine if the anemia has other causes besides iron deficiency.

Iron deficiency can cause anemia, a shortage of hemoglobin in the blood. This can lead to weakness, fatigue, a pale face and earlobes, and brittle, spoon-shaped nails. There are other causes of anemia besides nutritional deficiencies, including massive or chronic blood loss.

The best way to tell if you have enough iron in your body is to find out if you have enough iron in your blood. A "finger-stick hemoglobin" check can be done in your doctor's office. This test requires only one tiny drop of blood, and the results are available within a few minutes. Pediatricians often use this test to check hemoglobin levels in nine-to fifteen-month-old infants. Your doctor may check hemoglobin levels at other ages of increased iron needs too, such as during female adolescence or pregnancy. Normal hemoglobin values are:

• infants and children 11 to 13 grams
• women 12 to 16 grams
• men 14 to 18 grams

You can prevent iron-deficiency anemia by making wise food choices for yourself and your family. Getting your daily iron from food is preferable to taking iron supplements, which sometimes cause abdominal discomfort and constipation. Here are some ways to assure there is enough iron in your family's diet.

1. Breastfeed your baby as long as possible. Once upon a time it was believed that breastfed babies needed iron supplements because human milk was low in iron. Yet, breastfed babies studied at four to six months of age had a higher hemoglobin than infants who were fed iron-fortified formula. Breastfed babies have been found to have sufficient iron stores for nine months or longer. Human milk remains an important part of baby's diet, even after the introduction of solids.

2. Use an iron-fortified formula. If bottlefeeding, use an iron-fortified formula, preferably beginning at birth, but at least starting by three months of age. Continue iron-fortified formula for at least one year or as long as your baby's doctor recommends, which is usually until your infant is eating adequate amounts of other dietary sources of iron. Do not use "low-iron" formulas, which do not contain sufficient iron for a growing baby's needs.

3. Delay cow's milk feeding for infants; limit it for toddlers. The Committee on Nutrition of the American Academy of Pediatrics recommends that parents delay using cow's milk as a beverage until a baby is at least one year of age. There are two iron-related reasons for this: cow's milk is low in iron, and cow's milk can irritate the intestinal lining, causing bleeding and the loss of iron. This is a tiny amount of blood loss, but over a long period of time it can be significant. The combination of poor iron intake and increased iron loss sets a baby up for iron deficiency anemia, and excessive milk consumption is a common cause of iron deficiency anemia in toddlers. An eighteen-month-old who consumes forty ounces of milk a day may be plump, but is probably very pale. Unless advised otherwise by your baby's doctor, limit your toddler's cow milk intake to no more than 24 ounces a day.

4. Combine foods wisely. Eating a food rich in vitamin C along with a good iron source will help your body use the iron. Here are some classic examples:
   • spaghetti with meat and tomato sauce
   • meat and potatoes
   • chicken fajitas with broccoli, sweet pepper, and tomatoes
   • hamburger and coleslaw
   • nitrate-free hot dogs and orange juice
   • fruit, iron-fortified cereal, and raisins
   • fresh fruit with raisins

5. Try prune juice as a regular beverage. Prune juice is one of the few juices that is high in iron (3 milligrams of iron per cup). The process involved in making prune juice retains more of the fruit's original nutrients than the juicing of other fruits.

   NUTRITIP Don't Skin the Iron Leave the skin on the potatoes when making homemade fries. This way you'll get more nutrition into a french-fry-loving picky eater. The potato skin is rich in nutrients and contains five times the amount of iron as the whole rest of the potato. Compliment those restaurants who have the nutritional wisdom to leave the skins on the fries. And, don't forget to eat the skin on your baked potato.

6. Cook in iron pots. The acid in foods seems to pull some of the iron out of the cast-iron pots. Simmering acidic foods, such as tomato sauce, in an iron pot can increase the iron content of the brew more than ten-fold. Cooking foods containing other acids, such as vinegar, red wine, lemon or lime juice, in an iron pot can also increase the iron content of the final mixture.

7. Bake with iron-rich grains. The usual wheat used to make bread and pastries is relatively low in iron (around one milligram of iron per half cup). Lesser known grains, such as amaranth (8 milligrams per half cup) and quinoa (9 milligrams per half cup) are much richer in iron. Barley grains contain four milligrams of iron per half cup. Mixing these grains into the wheat flour you use when you bake will increase the iron content of the finished product.
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   Look out for misleading labels.
   The percentage of iron listed on the package label is certainly not the amount of iron that gets into your bloodstream. This is especially true of iron-fortified cereals, in which only 4 to 10 percent of the iron listed actually gets absorbed. The amount of iron absorbed from any food depends on the type of iron in the food, the body's need for iron, and the company of other foods eaten at the same meal.
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   "My doctor measured my hemoglobin and it's normal. Could I still be anemic?"

   A normal hemoglobin level does not necessarily indicate that you are not anemic, meaning your blood is not low in iron. Yet, the hemoglobin level obtained in your doctor's office does not reflect total body stores of iron. It's possible to have a normal hemoglobin, that is, a normal amount of iron in the blood, yet have vital tissues throughout your body deficient in iron. Some people have symptoms of iron-deficiency anemia, even with a normal hemoglobin. To really be sure you have enough iron in your body, your doctor may send you to the laboratory to measure the serum ferritin, the level of iron in blood that accurately reflects iron stores. (Normal values are 7 to 140 micrograms per liter (mcg/l) in children, 20 to 120 micrograms in women, 20 to 300 micrograms in men.) If your serum ferritin level is normal, you can rest assured that you have adequate iron stores throughout your body.

   Serum ferritin levels detect iron deficiency in the early stages; a low hemoglobin reflects a much later stage of iron deficiency. This is an important consideration, since with a normal hemoglobin and low ferritin levels the iron stores can be restocked by simply increasing the amount of iron in your diet. By the time the hemoglobin is low, iron supplements are usually needed. Symptoms of iron deficiency anemia, such as being tired, irritable, and having difficulty concentrating, may be present long before anemia is reflected by the hemoglobin tests. That is why a serum ferritin is an earlier and more sensitive indicator of iron deficiency.