Iron deficiency is a common nutritional deficiency affecting children. Although there are no Australian prevalence estimates for iron deficiency in infants and toddlers, a 2022 study found that 75% of older infants (6 to 11.9 months old) and one quarter of toddlers (12 to 24 months old) had inadequate iron intakes.¹ While the more common signs of anaemia are well known, it can present differently in very young children. This case study describes an unusual presentation of iron deficiency anaemia in a young child.

Initial Presentation

An 18-month-old girl presented in clinic with her parents, suffering from breath-holding spells. When very upset or hurt, she would cry and exhale all her air, then hold her breath until she turned blue and lost consciousness. Once she had lost consciousness, she began breathing normally and quickly came back around. These episodes were occurring several times every day. They had seen their GP who ruled out cardiac and neurological causes. They were advised that while the spells are involuntary, they are essentially benign and she will outgrow them by the time she is 4 to 6 years old, with no treatment required. However, her parents understandably found the episodes terrifying and hoped some natural treatment may help.

The child was generally healthy, reaching development and growth milestones appropriately. Her birth was an uncomplicated vaginal delivery, and she was breastfed until 12 months of age. She was emotionally volatile, irritable and easily overtired. Her sleep patterns were poor, with frequent overnight waking. She was an extremely picky eater with a low appetite for food. Her diet was high in refined carbohydrates and low in fresh fruits, vegetables and protein. She was drinking up to 900 mL of cow’s milk daily from a bottle, with several bottles overnight. She had pale conjunctiva, brittle nails with white spots and a tongue quiver.

Treatment Plan

Breath-holding spells are associated with iron deficiency in children.² High cow’s milk consumption, particularly from a bottle, greatly increases the risk of iron deficiency anaemia.³ Cow’s milk is low in iron, and large intake may reduce the consumption of foods that do contain iron. Additionally, calcium and casein in milk bind to dietary non-haem iron, reducing iron absorption. Drinking milk from a bottle and feeding to sleep with a bottle increases the total consumption of milk by reducing the ability of the baby to self-regulate their consumption.³

Her physical examination found signs of iron and other mineral deficiencies, including magnesium and zinc. It is therefore important to refer for blood tests to assess iron status, while improving iron intake and general nutrition.

Prescription

• Blood test referral for full blood count and iron studies

• Liquid Iron Supplement, containing iron gluconate 9.58 mg, thiamine hydrochloride (vitamin B1) 1.14 mg, riboflavin sodium phosphate (vitamin B2) 1.13 mg, pyridoxine hydrochloride (vitamin B6) 1.05 mg, and cyanocobalamin (vitamin B12) 860 ng, in a base containing herbs, fruits and vegetable juices: 10 mL once daily

• Children’s Multivitamin Powder, containing vitamins and minerals in highly absorbable forms, including iron bisglycinate 2.5 mg, magnesium citrate 86 mg and zinc citrate 4 mg: 3 g once daily

• Reduce cow’s milk consumption to a maximum of 500 mL per day. Switch to an open cup rather than a bottle for milk through the day. Reduce milk consumption overnight. Try to settle back to sleep without milk, offering water instead.

• Increase consumption of iron-rich foods, including red meat, liver, spinach, legumes, and ground nuts

2-Week Follow-Up

The blood tests confirm iron deficiency and mild microcytic anaemia, with her ferritin low at 10 μg/L and haemoglobin low at 92 g/L. Compliance with the supplements has been good. Cow’s milk consumption has decreased to approximately 600 mL per day, and they have switched to an open cup rather than a bottle during the day. They are still feeding to sleep with a bottle at night; however, they have reduced overnight feeds to one bottle per night. The breath-holding spells have continued without major changes. Dietary changes have been difficult as the child has a poor appetite for food, preferring milk. 

Treatment Plan

Increase the dose of iron to address anaemia while improving diet. Provide support to assist parents in implementing dietary changes

Prescription

• Liquid Iron Supplement: 10 mL twice daily

• Children’s Multivitamin Powder: 3 g once daily

• Resources on improving diet for fussy eaters

• Resources on improving sleep in toddlers

6-Week Follow-Up

Compliance has been very good. Cow’s milk consumption is down to 400 mL per day from a cup only. They have ceased all bottles and are no longer feeding to sleep or offering bottles overnight. While this was a slightly difficult transition, her sleep has markedly improved with no overnight waking on most nights. Her appetite has also improved with the reduction in cow’s milk, and she is happier to try new foods. The breath-holding spells have noticeably reduced, with only three episodes the previous week.

Treatment Plan

Maintain current treatment while continuing to improve the diet.

Prescription

• Liquid Iron Supplement: 10 mL twice daily

• Children’s Multivitamin Powder: 3 g once daily

• Blood test referral for full blood count and iron studies to be repeated at 12 weeks post-initial consultation

14-Week Follow-Up

Compliance has been fantastic. The blood tests show great improvement, with both ferritin and haemoglobin within healthy range for her age group. The breath-holding spells have essentially ceased, with only one episode in the past three weeks. Her sleep has been good, and her mood is noticeably calmer. Her appetite has continued to improve. While her vegetable consumption could be better, she is eating a much wider variety of foods, including iron-rich foods.

Treatment Plan

Continue iron and multivitamin supplementation at a low dose for three months to ensure stores are fully replenished.

Prescription

• Liquid Iron Supplement: 5 mL once daily

• Children’s Multivitamin Powder: 3 g once daily

Clinical Thoughts

Iron deficiency is extremely common in young children, but it is often missed in routine practice. This can have long-term health consequences for the child. Greater awareness of the more unusual symptoms of anaemia in this age group will improve diagnosis and treatment rates.

References

1. Moumin NA, Netting MJ, Golley RK, Mauch CE, Makrides M, Green TJ. Usual nutrient intake distribution and prevalence of inadequacy among Australian children 0-24 months: findings from the Australian Feeding Infants and Toddlers Study (OzFITS) 2021. Nutrients. 2022 Mar;14(7):1381. DOI: 10.3390/nu14071381

2. Shah M, Mendez MD. Breath-holding spells [Internet]. Treasure Island: StatPearls; 2023 [cited 2026 Jul 7]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539782/

3. Parkin PC, DeGroot J, Maguire JL, Birken CS, Zlotkin S. Severe iron-deficiency anaemia and feeding practices in young children. Public Health Nutr. 2016 Mar;19(4):716-722. DOI: 10.1017/S1368980015001639