Vitamin D and iron drops, and which babies really need them

Every breastfed baby should get 400 IU of vitamin D a day, from the first days of life through the first year, even in sunny India. Iron is different. Babies born early or small need iron drops, while most healthy full-term babies need iron-rich foods from 6 months instead. Here is the reasoning behind both bottles.

Why does my baby need vitamin D?

Vitamin D helps the gut absorb calcium and phosphate, which growing bones need. Without enough, bones become soft and bend, a condition called rickets.¹

Signs of rickets include bowed legs, thick wrists, a bumpy ridge along the ribs, a soft spot on the head that closes late, and late teeth and walking. In young babies, very low calcium from a lack of vitamin D can even cause fits.

A global expert group calls rickets a preventable public health problem, and says supplements and food fortification are urgently needed to wipe it out.¹ Vitamin D is also linked with muscle and immune health, though many of the wider claims made for it are not well proven.

How much vitamin D should I give my baby?

400 IU a day. This is the dose advised by both the Indian Academy of Pediatrics (IAP) and the American Academy of Pediatrics (AAP).^2,3

The AAP advises starting soon after birth.³ The IAP recommends 400 IU a day throughout infancy.² In practice Dr Dutta starts it in the first week and continue until the first birthday.

Drops come in different strengths. Some brands give 400 IU in one drop, others in 1 mL. Read the label every time you buy a new brand, and ask your doctor if you are unsure.

Does a breastfed baby really need vitamin D drops?

Yes. Breast milk is the best food for your baby, but the AAP advises vitamin D drops for all babies, including those who are only breastfed.³

This is not a fault in breast milk. It reflects how little vitamin D most mothers have. In a US trial, mothers who took a high dose of 6,400 IU a day made milk with enough vitamin D for their babies.⁴ That is an option to discuss with your doctor, but giving the baby 400 IU drops is simpler and is what most guidelines advise.

Formula is fortified with vitamin D. A baby who drinks a lot of formula gets some from her feeds. Most young babies in India are fully or partly breastfed, so Dr Dutta usually advises the drops for them too.

Why are Indian babies low in vitamin D despite all the sunshine?

Because sunshine on skin is not the same as sunshine in the sky. Studies from India have found very high rates of low vitamin D in pregnant women and newborns.⁵

In one study from Lucknow, 84% of pregnant women had vitamin D levels low enough to upset their calcium balance, and their newborns' levels were even lower.⁵ The authors called this unexpected in a tropical country.⁵

The likely reasons:

• Darker skin needs longer in the sun to make the same amount of vitamin D.
• Most skin stays covered, and many women spend the day indoors.
• We sensibly avoid the midday sun, when it makes the most vitamin D.
• City smog filters out the useful rays.
• Few Indian foods are rich in vitamin D, and many families are vegetarian.

Can sunlight replace vitamin D drops for my baby?

No. Nobody can tell you how many minutes of sun on how much skin will give a particular baby enough vitamin D, and strong sun can harm a baby's skin.³

The AAP moved to drops for all babies partly because safe sun exposure is so hard to judge for any one child.³ Young babies also overheat and burn easily in direct sun.

A short spell of gentle morning sun during the traditional oil massage is pleasant, and Dr Dutta has no objection to it. But it is not a substitute. Drops are cheap, safe at the right dose, and reliable.

Should I take vitamin D myself while pregnant or breastfeeding?

Ask your obstetrician. A baby's vitamin D stores at birth depend on the mother's level in pregnancy.⁵

In the Lucknow study, mothers' vitamin D levels closely tracked their newborns' levels.⁵ A mother who is low during pregnancy has a baby born with low stores.

An international expert group lists risk factors for rickets in mothers as well as babies, and advises prevention for both.¹ Many mothers in India also get too little calcium from their diet.⁵ Your obstetrician can advise on a suitable vitamin D and calcium plan for you, and it does not replace your baby's own drops unless your doctor says so.

Can my baby get too much vitamin D?

Yes. At 400 IU a day it is very safe, but very large doses can raise calcium in the blood to harmful levels.²

High doses are used only to treat a proven deficiency, under a doctor's care. Even then, the IAP prefers daily doses over large single "shots" for babies.²

• Do not double the dose because you missed a day. Just carry on.
• Do not give two products that both contain vitamin D without asking.
• Keep the bottle out of reach of older children.

Why does my baby need iron?

Iron is needed to make haemoglobin, which carries oxygen in the blood, and it is vital for brain growth in the first two years.⁶

Iron deficiency in infancy, even before it causes anaemia, has been linked with long-lasting effects on learning, movement and behaviour.^7,6 Studies that followed children into school age and beyond found poorer thinking, motor and social skills in those who were iron deficient as babies.⁷

Young children are at special risk because they grow so fast.⁸

How common is anaemia in Indian babies?

Very common. In the latest National Family Health Survey (NFHS-5, 2019 to 2021), about 67% of Indian children aged 6 to 59 months had anaemia.⁹

That was a rise from about 59% in the survey before.⁹ Not all anaemia is due to lack of iron, but much of it is.

Common causes Dr Dutta sees in Kolkata include:

• anaemia in the mother during pregnancy
• starting solids late, or giving watery first foods
• cow's or buffalo milk as the main drink before age 1⁸
• tea given to toddlers with meals
• too few iron-rich foods such as egg, fish, meat and dal⁸

Does a full-term breastfed baby need iron drops?

Usually not. A healthy full-term baby is born with iron stores that, together with breast milk, usually cover her early months. From 6 months, every baby needs iron-rich foods.⁸

European experts found too little evidence to give routine iron drops to all healthy babies of normal birth weight.⁸ The AAP stresses that iron deficiency should be prevented and screened for in all young children.⁶

Dr Dutta's own approach depends on risk. Anaemia in the mother, a baby growing very fast, early cord clamping, or a family diet low in iron make her more likely to suggest drops or to check the baby's blood.

Does delayed cord clamping help my baby's iron?

Yes. Waiting before clamping the cord lets extra blood flow from the placenta into the baby, which builds her iron stores.¹⁰

A Cochrane review found that babies whose cord was clamped early had more than double the risk of iron deficiency by 3 to 6 months of age.¹⁰ Delayed clamping did lead to slightly more jaundice needing light treatment.¹⁰

European experts list delayed cord clamping as one way to reduce iron deficiency.⁸ Ask your obstetrician about it before the birth.

Why do premature and low birth weight babies need iron drops?

Because they missed some or all of the last months of pregnancy, when most iron moves from mother to baby. They also grow fast after birth, so their stores run out early.

A Cochrane review found that iron supplements gave preterm and low birth weight babies a slightly higher haemoglobin, better iron stores and less iron deficiency anaemia.¹¹ Doses higher than the usual 2 to 3 mg per kg per day gave no extra benefit.¹¹ Even babies born only slightly small, between 2 and 2.5 kg, are advised to get iron drops.⁸

Your neonatologist will work out the dose by weight and adjust it as your baby grows. Please do not work it out yourself.

Which foods give my baby iron after 6 months?

From 6 months, every baby should get iron-rich foods every day, including meat, fish or egg, or iron-fortified foods.⁸

• egg, fish, chicken and meat, whose iron is best absorbed
• dal, rajma, chana and other pulses
• ragi and green leafy vegetables such as palak
• a fruit or vegetable rich in vitamin C at the same meal, such as orange, guava or tomato, which helps the body take up plant iron

Avoid cow's or buffalo milk as the main drink before 1 year.⁸ It is low in iron and reduces how much iron the body absorbs.¹² Keep tea away from babies altogether.

What side effects can iron drops cause?

Iron drops often turn stools dark green or black. This is harmless.

• Some babies get constipated or have a mild tummy upset.
• Iron can stain teeth. Drop it towards the back of the mouth, and wipe or brush the teeth afterwards once they appear.
• Give it at the time your doctor suggests, often between feeds.

Iron is dangerous in overdose. Adult iron tablets are a classic cause of serious poisoning in toddlers. Store all iron products, including your own pregnancy tablets, locked away.

When should I talk to my doctor about vitamin D or iron?

See your paediatrician if your baby:

• looks pale, especially the palms, inner eyelids and lips
• is unusually tired, irritable or has a poor appetite
• eats mud, chalk or paint as a toddler (called pica)
• has legs that bow more as she starts to stand, or thick wrists
• has late teeth or late walking
• was born early or small and has not been started on iron

Seek urgent help if a young baby has a fit, or if anyone at home has swallowed iron tablets or a large amount of any vitamin product.