Anaemia in children: why it is so common in our region and what to do about it

What is iron deficiency anaemia and how does it affect your child?

Anaemia means there is not enough haemoglobin (Hemoglobin) in the blood. Haemoglobin is the protein inside red blood cells that carries oxygen to every organ and muscle in the body. When iron stores run low, the bone marrow cannot make enough healthy red blood cells, and your child's tissues start receiving less oxygen than they need. The result is a child who tires easily, looks pale, and struggles to keep up with other children their age.

Many parents notice the pallor or the fatigue but do not connect it to iron. The symptoms build slowly, so by the time they are obvious the deficiency has often been present for months. A child who stops wanting to run around, who seems always sleepy, or who cries more than usual may simply need their blood checked before anything else.

The reason this matters beyond tiredness is the developing brain. Iron is essential for building myelin, the insulating sheath around nerve fibres that allows the brain to process and transmit signals quickly. A shortage of iron during the early years of life can leave a lasting mark on cognitive ability, and this is reflected in a body of research linking childhood anaemia to lower school performance.

How common is the problem across the Middle East?

Iron deficiency anaemia is not a fringe problem in this region. Research on children in Gulf countries documented in the Nutrition and Health journal found that iron deficiency anaemia was affecting a significant proportion of children under five, with the burden higher in lower-income and rural populations. In parts of Yemen, Sudan and Syria, rates are among the highest in the world, driven by food insecurity and disrupted feeding practices.

A 2022 review in the Saudi Medical Journal covering nutritional status across the Eastern Mediterranean confirmed that iron deficiency remains one of the dominant nutritional problems in the region, with children under five and women bearing the largest share. Children living in areas of conflict or displacement face the greatest risk, since access to iron-rich foods disappears and feeding routines collapse.

A 2018 study in the Journal of Pediatric Gastroenterology and Nutrition specifically examined complementary feeding practices across the Middle East and North Africa, and found that delays in introducing iron-rich solid foods and reliance on low-iron staples were directly contributing to the high rates of iron deficiency seen in the region.

The cow's milk problem that surprises most parents

One of the most common and least expected causes of iron deficiency in toddlers is too much cow's milk. Cow's milk contains very little iron, and what little is there is poorly absorbed. A 2011 review in Nutrition Reviews explained the mechanism clearly: cow's milk protein can irritate the lining of a young child's small intestine, causing microscopic blood loss that steadily drains iron from the body. On top of this, a stomach full of milk leaves a child with little appetite for the iron-rich foods they actually need.

The practical result is that a toddler drinking large volumes of cow's milk every day is almost certainly not eating enough meat, lentils, or other iron-rich foods. Their iron intake from the milk itself is negligible, but the milk fills them up and crowds out everything else. This is not a reason to remove dairy from a child's diet, but it is a strong reason to set a limit.

Current guidance is that cow's milk should not exceed about 480 ml per day for children between one and three years of age. Cow's milk should not be given at all before 12 months. Within those limits, dairy is a nutritious part of a child's diet. Beyond them, it becomes a contributor to iron deficiency.

Which children are at highest risk?

Risk is not evenly distributed. Babies born prematurely or with low birth weight enter the world with smaller iron stores, because the fetus builds most of its reserves in the last trimester of pregnancy. A baby born at 34 weeks has missed six weeks of that process. Fully breastfed infants who do not receive iron-rich complementary foods from six months onward are another well-documented high-risk group, because breast milk, while well-absorbed, cannot by itself meet the growing baby's iron needs after that point.

Children aged 6 months to 2 years are in the highest-risk window because their growth demands outstrip what most typical regional diets supply. Teenage girls who have started their period face another surge in risk, since menstrual blood loss drains iron every month and most diets do not compensate for it.

Additional risk factors common in this region include repeated episodes of diarrhoea and intestinal parasites such as hookworm, which cause slow blood loss in the gut. Children from families who eat little meat for economic or cultural reasons rely entirely on non-heme iron from plant foods, which is absorbed at a much lower efficiency than the heme iron (Heme iron) found in meat and offal.

How is anaemia diagnosed in children?

Diagnosis starts with a full blood count (CBC), which measures haemoglobin levels and red blood cell size (MCV, Mean Corpuscular Volume). In iron deficiency anaemia, red blood cells are small and pale, reflected by a low MCV and low haemoglobin. The World Health Organization defines anaemia in children under five as haemoglobin below 11 g/dL, and in children aged 5 to 11 as below 11.5 g/dL.

A low haemoglobin alone does not confirm that iron is the cause. The doctor will usually add a ferritin (Ferritin) test to measure the body's stored iron. Low ferritin means the iron reserves have been depleted. A complication worth knowing is that ferritin is an acute-phase protein: it rises with any inflammation, so a normal ferritin does not always rule out iron deficiency in a child who is also fighting an infection. Your doctor will read it alongside other markers. In smaller clinics across the region where the full panel is not available, physicians sometimes start an empirical trial of iron supplements and judge the response by repeat haemoglobin four to six weeks later.

If your child's haemoglobin comes back low, ask the lab for the MCV and ferritin as well. Knowing both helps your doctor distinguish iron deficiency from other causes of anaemia such as thalassaemia or folate deficiency, which require completely different approaches.

The best iron-rich foods for children in a regional kitchen

Dietary iron comes in two forms. Heme iron (Heme iron), found in meat, poultry and fish, is absorbed at 15 to 35 percent. Non-heme iron (Non-heme iron) from lentils, chickpeas, beans and leafy vegetables is absorbed at only 2 to 20 percent, depending on what else is eaten with it. This gap explains why children who eat no meat need considerably larger portions of plant foods to get the same amount of iron, and why pairing plant-based iron with vitamin C is so effective at narrowing that gap.

In a typical Arab kitchen, excellent iron sources are available and affordable. Liver, especially chicken and beef liver, is among the richest food sources of iron anywhere and a small serving once a week makes a real difference for a young child. Lentils in all forms and chickpeas are outstanding plant sources. Spinach and other dark leafy greens contain iron but it is poorly absorbed on its own. The fix is simple: serve them with a squeeze of lemon juice or alongside tomatoes, and absorption improves noticeably.

One practical point that is often missed: tea and coffee significantly reduce iron absorption when drunk with or shortly after a meal. In many households across the region, young children are given herbal tea or black tea after eating as a matter of habit. Waiting at least an hour after a meal before giving tea protects the iron that the meal delivered. Calcium from dairy also competes with iron absorption, which is another reason not to wash down an iron-rich meal with a glass of milk.

When does a child need iron supplements?

Do not start iron supplements before seeing a doctor. Excess iron can be harmful, and some children carry conditions such as thalassaemia (Thalassemia) that mimic iron deficiency on a blood test but are made worse by iron supplementation. Getting the right diagnosis first protects your child.

When iron deficiency is confirmed, the doctor will usually prescribe iron drops or syrup. The taste is often bitter and the stool may turn dark green or black, which is normal and not a reason to stop. Iron supplements work best on an empty stomach or with a small glass of orange juice, which boosts absorption. Avoid giving them with milk, tea or calcium-containing foods, as these block absorption.

Treatment usually continues for 3 to 6 months after the haemoglobin has returned to normal, because the body needs that extra time to refill its iron stores. Stopping too early is the most common reason for the anaemia coming straight back. Follow-up blood tests, usually at 4 to 6 weeks after starting, confirm that the haemoglobin is rising as expected and allow the doctor to adjust the dose.

How does anaemia affect learning and growth?

The consequences go well beyond a pale face. A 2022 systematic review in the journal Nutrients examined the evidence on iron status, anaemia and academic performance in young people, and found a consistent link between iron deficiency and lower scores on tests of attention, memory and school achievement. The effect was seen even in children who were iron-deficient but not yet fully anaemic, meaning the impact on thinking begins before the haemoglobin falls below the diagnostic threshold.

The underlying reason is that the brain in early childhood is in a critical window of development. Iron is needed to synthesise myelin, the protective coating around nerve fibres, and to produce neurotransmitters that govern mood and attention. A deficiency during this period can disrupt the architecture of the brain itself, not just slow it down temporarily, and some studies suggest that effects on cognition may persist even after the anaemia is treated.

In practical terms, if your school-age child is falling behind in class, seems distracted or irritable, and also looks tired or pale, a blood test is worth doing before any other explanation is explored. Anaemia is one of the most treatable causes of those symptoms, and it is regularly missed because the connection between the blood and the brain is not obvious to most parents.

Prevention: protecting your child before problems start

Prevention is simpler and cheaper than treatment. The most important step is to introduce iron-rich complementary foods at six months of age rather than waiting for the child to show obvious interest. Pureed liver, soft-cooked lentils and minced meat are all appropriate from six months and provide far more iron than rice or bread-based weaning foods. A 2018 review in the Journal of Pediatric Gastroenterology and Nutrition noted that delayed introduction of these foods was a key driver of iron deficiency across the MENA region.

Premature infants often need iron supplementation from as early as one month of age, at a dose that the neonatologist or paediatrician will specify. Do not assume that a supplement given in hospital will continue automatically after discharge. Ask the doctor about it at every follow-up visit in the first year.

For older children, routine blood checks at well-child visits allow the doctor to spot falling haemoglobin before full anaemia develops. Do not wait for visible symptoms. The body compensates for iron deficiency for a long time before the haemoglobin falls below the diagnostic threshold, and by the time symptoms are obvious the deficiency has often been present for many months.

Sources

• Musaiger AO: Iron deficiency anaemia among children and pregnant women in the Arab Gulf countries: the need for action, Nutrition and health, 2002
• Lifschitz CH, Miqdady M, Indrio F et al: Practices of Introduction of Complementary Feeding and Iron Deficiency Prevention in the Middle East and North Africa, Journal of pediatric gastroenterology and nutrition, 2018
• Ziegler EE: Consumption of cow's milk as a cause of iron deficiency in infants and toddlers, Nutrition reviews, 2011
• Samson KLI, Fischer JAJ, Roche ML et al: Iron Status, Anemia, and Iron Interventions and Their Associations with Cognitive and Academic Performance in Adolescents: A Systematic Review, Nutrients, 2022
• Gedfie S, Getawa S, Melku M et al: Prevalence and Associated Factors of Iron Deficiency and Iron Deficiency Anemia Among Under-5 Children: A Systematic Review and Meta-Analysis, Global pediatric health, 2022
• Al-Shameri EA, Al-Shahethi AH, Wafa SW et al: Nutritional status and its determinants in the Eastern Mediterranean region. A review, Saudi medical journal, 2022