Anaemia in children in India is common and mostly preventable

About two in three Indian children aged 6 months to 5 years have anaemia. The most common cause is iron deficiency, which is largely preventable with iron-rich food, sensible amounts of milk, deworming and supplements when needed. In West Bengal, thalassaemia trait is the other cause Dr Dutta always keeps in mind.

How common is anaemia in children in India?

Very common. The National Family Health Survey 5 (NFHS-5, 2019 to 2021) found anaemia in 67.1 percent of children aged 6 to 59 months.¹

That means most toddlers in a typical Indian playgroup are anaemic. Many look completely well, which is why Dr Dutta checks for anaemia in almost every toddler she sees, instead of waiting for symptoms.

What is anaemia in a child?

Anaemia means there is too little haemoglobin in the blood. Haemoglobin is the red protein in blood cells that carries oxygen to the body and the growing brain.

Doctors diagnose anaemia when the haemoglobin falls below a set level for the child's age and sex.² In 2024 the WHO revised these cut-off levels, including the ones for children aged 6 to 23 months.³

Anaemia is a sign, not a final diagnosis. Your doctor's next job is to find out why it has happened.

What causes anaemia in children?

Iron deficiency, usually from too little iron in the diet, is the most common nutritional cause.²

Other causes include:²

• Low folate, vitamin B12 or vitamin A.
• Infections, including worms such as hookworm, and malaria.
• Long-term illness and inflammation.
• Inherited blood conditions such as thalassaemia and sickle cell disease.

Low iron stores at birth also play a part.² In many children more than one cause is present.

What are the signs of anaemia in a child?

Mild anaemia often causes no signs at all. When it is more marked, a child may be tired, short of breath with effort, dizzy, or have cold hands and feet.²

In severe anaemia, you may see pale skin, pale nail beds, a pale inside of the lower eyelid, and fast breathing and heartbeat.²

Parents also mention other clues:

• A poor appetite.
• Irritability and poor concentration.
• Eating mud, chalk, ice or paper. This craving is called pica, and it often goes with iron deficiency.

Since signs come late, a simple blood test is the reliable way to know.

Does iron deficiency affect my child's brain and learning?

It can. Iron is needed for brain growth, not only for haemoglobin.

Follow-up studies of children who were iron deficient as babies have found poorer thinking, movement and social and emotional skills, from preschool into the teenage years.⁴ Iron helps build myelin (the insulation around nerve fibres) and brain chemical messengers.⁴

The American Academy of Pediatrics notes that iron deficiency in early childhood, even before anaemia appears, can have lasting effects on development, and asks doctors to work to prevent it.⁵ This is the main reason Dr Dutta takes it so seriously.

Which children are most at risk of iron deficiency?

Babies born small, toddlers who drink a lot of cow's milk, and children who get few iron-rich foods after 6 months are at highest risk.⁶ Low family income adds to the risk.⁶

From her own practice, Dr Dutta would add babies born premature, twins, and babies whose mothers were anaemic in pregnancy. If your child fits any of these, ask your paediatrician about a blood test and about iron drops.

Does delayed cord clamping prevent anaemia in babies?

Yes, it helps. Waiting before clamping the cord lets extra blood, and so extra iron, flow from the placenta into the baby.

In a Cochrane review, babies whose cords were clamped early had more than double the chance of iron deficiency at 3 to 6 months of age.⁷ European experts also say delayed clamping lowers the risk of iron deficiency.⁶ India's Anaemia Mukt Bharat programme asks health facilities to delay clamping by 3 minutes after delivery.¹

Ask your obstetrician about this before your delivery date.

Can too much milk cause anaemia in toddlers?

Yes. This is one of the commonest stories Dr Dutta sees: a toddler who drinks a litre of milk a day and eats very little.

Cow's milk has very little iron, and its calcium and casein reduce the iron absorbed from other foods.⁸ In babies under one, it can also cause small, hidden blood losses from the gut.⁸

European guidance says cow's milk should not be the main drink before 12 months, and toddlers should have less than 500 ml a day.⁶ Give milk after meals, from a cup, and without added sugar or malted powders.

Which Indian foods are rich in iron for children?

From 6 months, every baby needs iron-rich foods, such as meat or iron-fortified foods.⁶ Good choices in an Indian kitchen include:

• Fish, chicken, mutton and small amounts of liver. Soft, deboned fish mashed into rice is a fine weaning food.
• Eggs.
• Dals and pulses: masoor, moong, chana, rajma, soya.
• Ragi, bajra and other millets.
• Green leafy vegetables such as palak, methi, notey shak and lal shak, and drumstick leaves.
• Poha, dates and jaggery add a little iron, but less than many people think.

Iron from meat and fish is absorbed better than iron from plants. Vegetarian families can still do well by pairing iron foods with vitamin C.

Does vitamin C help my child absorb iron?

Yes. Vitamin C helps the gut take up iron from plant foods. It stops the iron forming compounds that cannot be absorbed, and changes it into a form the gut cells can take in.⁹

Simple ways to use this:

• A squeeze of lemon on dal or sabzi.
• A piece of guava, orange or amla with the meal.
• Tomato in the curry.

This costs almost nothing and is especially useful in vegetarian homes.

Is tea bad for a child with anaemia?

Yes. Tea blocks iron absorption, so Dr Dutta would rather young children did not drink it at all.

In a study in adult volunteers, tea reduced iron absorption from foods such as bread and rice, and the authors linked this to tannins (bitter compounds in tea) binding the iron.¹⁰ They warned that tea with meals may add to iron deficiency when the diet is mostly vegetarian.¹⁰

Many Indian children start sweet milky tea early, often with biscuits. If an older child does drink tea, keep it well away from meals.

Should I give my baby iron drops?

Some babies need them, but please ask your doctor before starting. The dose depends on age, weight and whether your child is already deficient.

European experts advise iron supplements for babies who were slightly low birth weight (2,000 to 2,500 grams).⁶ Premature and smaller babies are usually started on drops by their neonatal team. Under India's Anaemia Mukt Bharat programme, preventive iron and folic acid is given to children through the public health system.¹

An overdose of iron is dangerous for a small child, so keep the bottle locked away.

What is the Anaemia Mukt Bharat programme?

It is the Government of India's anaemia programme, launched in 2018, for children, adolescents and women.¹

Its main parts are:¹

• Preventive iron and folic acid supplements for each target age group.
• Year-round health messages on taking iron and deworming tablets, good infant feeding, and iron-rich foods.
• Delayed cord clamping at hospital births.
• Blood tests to find anaemia, and treatment for it.
• Attention to non-nutritional causes, including malaria and inherited haemoglobin disorders.

If your child goes to an anganwadi or a government school, ask whether they are receiving these.

How is iron deficiency anaemia treated in children?

With iron medicine by mouth, usually once a day, at a dose your doctor works out from your child's weight. The course lasts months, not weeks.

Your doctor will repeat the blood test after some weeks to check that the haemoglobin is rising. If it is not, the usual reasons are missed doses, worms or other blood loss, or a different cause such as thalassaemia trait.

Iron can upset the tummy, turns the stool black, and may stain the teeth. Brushing after the dose helps. The most common reason treatment fails is stopping as soon as the child looks better. Iron is continued after the haemoglobin is normal, to refill the body's stores.

Could my child's anaemia be thalassaemia trait?

Yes, especially in West Bengal. Thalassaemia trait can look like iron deficiency on a routine blood count.

A large Indian study of adults (college students and pregnant women) found beta thalassaemia trait in 2.78 percent of those screened across six cities. HbE trait (another inherited haemoglobin variant) was found in 3.92 percent in Kolkata.¹¹

Clues that point to trait are small red cells with a normal or high red cell count, a family history, and no improvement after a proper course of iron. The test that confirms it is HPLC (a test that separates the types of haemoglobin). Your doctor may also check ferritin (iron stores), because a child can have trait and iron deficiency together.

Why does thalassaemia trait matter for the family?

A carrier child is usually healthy and does not need iron unless iron is also low. But knowing you are a carrier matters for the next generation.

If both parents are carriers, each pregnancy has a one in four chance of a child with thalassaemia major, a serious condition needing lifelong blood transfusions. Carrier testing before marriage or early in pregnancy lets couples make informed choices. Giving iron again and again to a child who is not iron deficient does not help, so getting the diagnosis right saves months of wasted treatment.

When should I take my child to the doctor about anaemia?

Ask for a check, and a simple blood count, if:

• Your child looks pale, tires easily, or is short of breath with play.
• Your child eats mud, chalk, ice or paper.
• Your baby was premature or small at birth and is not on iron.
• Your toddler drinks a lot of milk and eats little food.
• Anaemia has not improved after a course of iron taken properly.
• Anyone in the family has thalassaemia, HbE disease, or is a known carrier.

Go to hospital the same day if your child is very pale and breathless at rest, has a racing heart, is unusually sleepy, or has black, tarry stools not explained by iron medicine, or blood in the stool.