Too much milk?
What's the risk?
Milk has been seen as the best drink to many parents for generations. That thought is being challenged and there are many who only drink milk alternatives. Although cow's milk has healthy protein and calcium, it has little iron and can lead to iron deficiency anemia if we consume too much. This is why pediatricians warn to limit milk in toddlers and young children.
How does milk cause anemia?
Cow's milk leads to microscopic blood loss from the gut. Less blood is produced because there's less iron in the diet. This combination leads to anemia.
Iron is used to build healthy red blood cells that carry oxygen throughout our bodies. Too few red blood cells in the body is called anemia. Red blood cells are made in our bone marrow and they live for about 3 months. It is important for the body to continually make new red blood cells as it breaks down and removes old ones.
In general anemia can be caused from several factors:
too little blood produced (iron deficiency being a major risk for this)
increased blood loss (excessive bleeding)
increased destruction of blood cells in the body (typically from abnormal blood cells or infection)
Iron deficiency can be due to several factors:
poor iron absorption due to disease (some studies show milk inhibits iron absorption)
poor iron in the diet (the most common cause)
long term slow blood losses (such as heavy monthly periods or GI bleeding)
increased iron need (such as a growth spurt or pregnancy)
What about non-dairy milks?
There are many milk alternatives to offer if a child is allergic to cow’s milk or if your family chooses to not offer cow’s milk, but most are not appropriate for toddlers.
HealthyChildren.org has a great summary of milk alternatives. A chart from the site shows a quick comparison of nutrients and calories. They are not equal, but none are good sources of iron and many don’t offer the protein and calories a young child needs.
Why does preventing iron deficiency anemia matter?
The most common symptom of anemia is no symptoms.
It can go unnoticed for quite a while in some kids, yet cause long term problems with growth and development. This is why the American Academy of Pediatrics (AAP) recommends testing for anemia between the ages of 9 to 12 months with additional testing for patients at risk.
Symptoms develop when the anemia becomes more severe and include tiredness, looking pale, irritability, decreased appetite, slowed development, weakness, immune dysfunction, and pica (eating non food substances- such as dirt).
Iron in breast milk and formula.
The iron in human milk is absorbed well and is sufficient for infants until about 4-6 months of age. Term babies who are exclusively should begin iron supplementation of 1mg/kg/day starting around 4 months of age and continue until iron containing foods are begun.
All preterm infants (born at less than 37 weeks gestation) should have iron intake of at least 2mg/kg/day through 12 months. Preterm babies fed human milk should receive supplemental iron per day starting by 1 month of age through 12 months of age. Exception—infants who have received multiple blood transfusions. Preterm infants fed standard term or preterm infant formulas should receive sufficient iron from formula, assuming full feeds from formula.
Iron is supplemented into formula, so infants can drink formula as a main nutrition source and get enough iron. Milk is not a source of iron, so if toddlers and children drink too much milk, they fill up on it. This limits the intake of other food groups that include iron and other important nutrients missing in their milk.
What about milk for babies?
Newborns are designed to drink their mother's milk. Humans have learned to make formulas that can nourish babies if they aren't able to drink their mother's milk for whatever reason.
Cow's milk, almond milk, soy milk, and goat's milk are not acceptable for infants due to their nutritional voids (not just iron). This is why infants should stay on breast milk or formula for the first year. (With recent formula shortages we have made a few exceptions, but this is a temporary measure done under special circumstances and should not become routine.)
After about 1 year of age toddlers may wean from mother's milk and/or formula onto whole milk. At this age they are typically able to eat other sources of nutrients in sufficient quantities.
More milk means less food - and less nutrition.
When kids fill up on milk, they don't eat as much as they should. It is recommended that toddlers drink no more than 24 oz/day of milk. Less is better if they are eating well and able to get all their calories from a variety of nutritious foods.
If young children prefer milk over foods, you may need to restrict the milk to trigger hunger cues and encourage them to eat more foods.
Too much milk can lead to undernourishment of many nutrients in addition to iron. Make sure your child eats a variety of fruits, vegetables, and proteins that include iron.
What about iron supplementation?
Children with a healthy diet rich in iron (see below) often do not need a supplemental iron. Foods rich in iron are listed below.
One way to increase the iron content in the diet is to use iron cookware. When you cook in an iron skillet (not a non-stick aluminum pan), it can improve the iron content of stove top meals. "Iron fish" are also sold to help increase iron in foods without the difficulty of cooking with non-stick skillets.
Consuming too much iron can have significant health risks. Because of this, supplements are not recommended for most people. If you are giving an iron supplement to your child (or take one yourself), blood tests on a regular basis may be needed to assure proper dosing.
A common temporary complication of liquid iron therapy is tooth staining. If the teeth become stained, the stain can be brushed off with a small amount of baking soda on a wet cloth. Many toothpastes have baking soda as a whitener and can be used by children.
The iron may change the color of bowel movements to dark green or black, but this is harmless.
Foods That Are Good Sources Of Iron
IRON COMES IN BOTH HEME AND NON-HEME FORMS.
Heme iron is found in animal foods that contain hemoglobin, such as meat, fish and poultry
Heme iron is the best form of iron, up to 40% of it is readily absorbed by your body
Non-heme iron primarily comes from plant sources and is present in grains, vegetables and fortified foods. This is the form added to foods enriched or fortified with iron, as well as many supplements.
Non-heme iron is absorbed much less efficiently than heme iron.
GOOD FOOD SOURCES OF HEME IRON INCLUDE:
Beef
Pork
Poultry — chicken, duck, and turkey, especially dark meat; liver
Veal
Fish such as halibut, haddock, perch, salmon or tuna
Shellfish such as clams, oysters and mussels
Red meats and organ meats like liver are particularly good sources.
GOOD SOURCES OF NON-HEME IRON INCLUDE:
Fortified cereals, rice, wheat and oats
Leafy greens of the cabbage family, such as broccoli, kale, turnip greens, collards
Dried fruits like raisins and apricots
Legumes, such as lima beans and green peas; dry beans and peas, such as pinto beans, black-eyed peas, and canned baked beans
Foods that inhibit iron absorption
Calcium is found in foods such as milk, yogurt, cheese, sardines, canned salmon, tofu, broccoli, almonds, figs, turnip greens and rhubarb and is the only known substance to inhibit absorption of both non-heme and heme iron.
To maximize absorption, calcium-rich foods should not be eaten with meals that provide most of your dietary iron.
Calcium and iron supplements should be taken at different times of the day, if possible.
Phytate, or phytic acid, is found in foods like whole grains, cereals, soy, nuts and legumes. Even a small amount of phytate can significantly decrease iron absorption.
The negative effect of phytate can be counteracted by consuming foods that enhance non-heme iron absorption, such as vitamin C or meat.
Polyphenols are found in various amounts in plant foods and beverages, including vegetables, fruits, some cereals and legumes, tea, coffee and wine.
To counteract the negative effect of polyphenols, take iron-rich meals and coffee and tea at separate times, since these drinks significantly decrease iron absorption.
