Iron Deficiency’s Long-Term Effects

An Interview with Pediatrician Betsy Lozoff

And there’s a great deal at stake. By failing to solve this problem for literally millions of youngsters around the globe, aren’t we risking that they won’t meet their full potential? And what about the potential of the nations where they live? Some economists have even suggested that wide-scale iron deficiency—and the related problems of poor school performance and lower productivity—can have a major effect on a nation’s entire economy and economic development.

In our field, there are still important unanswered questions about when and how much to intervene. We still don’t know things like when it’s best to test for iron deficiency anemia, whether iron deficiency without anemia has ill effects, or how early and how long to give iron to improve effects on brain and behavior. We do think we’ll be able to answer these questions in the coming years.

Another thing we’re really looking at now is the effect of a mother’s iron deficiency during pregnancy on the baby’s brain and behavior. Because the body produces more blood during pregnancy for the placenta and the baby, there’s an increased need for iron for both mother and baby, and a good diet alone can’t always meet that need. So this is a huge question, since it’s estimated that more than 50 percent of mothers in developing countries are anemic during pregnancy and iron deficiency in pregnancy is a problem everywhere.

What about children in the United States? Are there implications here at home, too?

It’s important to remember that this problem doesn’t affect the developing world alone. Even in the United States, iron deficiency remains a major public-health problem for infants. Despite all of our advances, we still see iron-deficiency anemia in 5 percent of poor Black and Hispanic infants and toddlers, and much higher levels of iron deficiency without anemia in some subgroups, such as Mexican-American children. Interestingly, these groups are at greater risk of iron deficiency regardless of their social and economic status, which suggests differences in infant diets or more iron deficiency during pregnancy may have a lot to do with the problem.

Recently, we’ve been studying infants from a poor area in Detroit, using brain-based measures. And we’re finding that iron-deficient anemic infants are worse in their motor coordination and motor sequencing. And once again, we’re seeing social-emotional differences—iron-deficient anemic infants seem more shy or hesitant, less engaged, less positive. We’re also studying the infants with “event-related potentials” (ERPs)—a way of looking at the brain’s activity in response to different stimuli—together with my National Scientific Council on the Developing Child colleague Chuck Nelson.

It sounds as though solutions to this pervasive health problem are within reach. Where are the areas of greatest promise?

Yes, we’ve made great strides in much of the industrialized world. But in many countries where iron deficiency is widespread, pediatricians and public health policy makers are looking for inexpensive ways to prevent iron deficiency in babies, at the same time avoiding anything that might interfere with breastfeeding, which is so important for infant health and development. In many situations, iron-fortified formula or iron-fortified commercial infant foods are not good solutions. But now there are some promising new developments. Scientists have been working to develop grains that have better iron absorption. Other efforts, for example in the Philippines and elsewhere, aim to fortify plain white rice with valuable nutrients, including iron. Yet other countries, like Vietnam, are fortifying other staple foods, such as fish sauce.

For infants, an approach I think holds great promise is home-fortification with something called “sprinkles.” A powdered, tasteless form of iron (mixed with vitamin C and other vitamins and minerals) can be provided in colorful little packets (like for sugar or sugar substitutes). They are designed to be sprinkled or stirred, one dose at a time, into any food the baby or toddler already eats. Studies by Dr. Stanley Zlotkin and his ­Canadian research team—in Ghana and Mongolia, for example—show the approach is very effective. It’s affordable and avoids many of the problems (like bitter taste or discoloration) associated with other approaches. Iron sprinkles aren’t commercially available yet, but the World Health Organization and other organizations have taken real interest in this effort. The goal is to have inexpensive, simple, and safe ways to prevent iron deficiency in infants and toddlers throughout the world.

The interviewer: Dorian Friedman is the policy editor at The American Prospect, a monthly political magazine, and a former associate editor at U.S. News & World Report. She is based in Washington, D.C.

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