Is there a link between IDA, cow’s milk intake, and bottle feeding?

A study from Canada demonstrates the burden of severe iron deficiency anaemia (IDA) among healthy children in the context of ongoing bottle feeding and excessive cow’s milk intake.

“Our population consisted of otherwise healthy children whose sole major medical condition was severe IDA … We sought to describe the burden of severe IDA, its associated complications and required interventions, and to identify risk factors for IDA in this setting,” said Dr Rachelle Zipper from The Hospital for Sick Children, Toronto, Ontario, Canada, at ASH 2025.

The team conducted a 5-year retrospective review of 128 children (median age 23 months) with very severe anaemia* seen at The Hospital for Sick Children between January 2020 and December 2024. The median haemoglobin (Hb) level was 3.8 g/dL, the median mean corpuscular volume (MCV) was 51.6 fL, and the median ferritin was 1.1 µg/L. [ASH 2025, abstract 2903]

Sixty percent of participants had thrombocytosis, which, according to Zipper, is classically associated with IDA. Fourteen percent had thrombocytopenia, with two patients being pancytopenic.

Approximately 90 percent of the children had poor appetite or refused to eat solid foods, 54 percent had hypoalbuminaemia, and a third had developmental delay.

Thirteen children underwent echocardiograms due to concerns with heart function. Of these, 11 had abnormal results: six had compensated dilated cardiac chambers, five had pericardial effusion, and three had cardiac dysfunction/failure.

Of the four patients who had a thrombotic event during their acute presentation, two had a cerebral sinus venous thrombosis (CSVT), one had a line-related deep vein thrombosis, and one had both.

A 27-month-old female patient (Hb 1.9 g/dL) died from cardiac failure and a CSVT/stroke. Another 22-month-old female patient (Hb 2.4 g/dL) died of cardiac failure and cardiac arrest. Both patients consumed 2L/day of cow’s milk and used a bottle.

Seventy-three children were hospitalized, 61 received ≥1 red blood cell transfusion, and 27 received ≥1 IV iron infusion.

Milk intake, bottle concerns

Approximately 90 percent of participants consumed >500 mL/day of cow’s milk (56 percent >1,000 mL/day). Among participants ≥1 year, 93 percent had a documented use of a bottle with a nipple.

“Excessive cow’s milk intake (>500 mL/day) is the single most common piece of dietary history in this age group that is considered a leading cause of IDA,” Zipper noted. “The main risk factor for this is thought to be the ongoing use of a bottle with a nipple after 1 year of age, which encourages children to consume more milk.”

Excessive milk intake contributes to IDA by reducing a child’s appetite and interest in iron-rich foods and causes gastrointestinal mucosal damage. [Nutrients 2021;13:828]

A preventable issue

“Our study demonstrates the tremendous morbidity and mortality that can occur from severe IDA in otherwise healthy children. These complications and interventions are generally completely avoidable,” Zipper highlighted. “The study also paralleled no literature on excessive cow’s milk consumption and bottle use being a primary correlate with severe presentation.”

“It is important to remember that, by focusing on patients with severe IDA, we are only capturing the tip of the iceberg when it comes to patients with less severe cases of IDA, [which may] also contribute to a lot of morbidity and healthcare resource utilization,” she continued.

Zipper reiterated that healthcare providers and families must be educated about the risks of IDA and appropriate preventive strategies, including dietary counselling, limiting cow’s milk intake, and, importantly, discontinuing the use of a bottle with a nipple once a child is 1 year old.