Iron deficiency usually results from poor dietary sources of iron, early introduction of cow’s milk, or intestinal blood loss due to milk intolerance.21,25,26lthough iron deficiency is a common cause of anemia, iron deficiency without anemia can have adverse effects on neurodevelopment and behavior that may be irreversible; cognitive deficits have been detected 10 or 20 years after iron deficiency in infancy.26

In addition, a linear association exists between the degree of iron deficiency and effects on infant social and emotional behavior, including increasing shyness, decreasing orientation and engagement, and a decreasing ability to be soothed.27

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A toddler diet should include iron-fortified cereals, red meat, vegetables containing iron, and fruits containing vitamin C (which promotes absorption of iron) to meet the recommended iron intake of 7 mg/day.26

Overconsumption or underconsumption of cow’s milk—an important source of protein, calcium, and vitamins A and C for toddlers—also can contribute to nutritional deficits.3Some parents may mistakenly provide more than the recommended two to three daily servings of milk to the detriment of iron intake from other healthy foods.3 

Juices, soda, or other sweetened beverages are often exchanged for milk, reducing the child’s daily calcium intake to a degree that can retard tooth development and bone growth.3

Vitamin D is essential for the absorption of calcium in the GI tract. Low levels can lead to decreased calcium absorption that may result in rickets.21 Fortified infant/toddler formula, cow’s milk, and cereals generally provide sufficient vitamin D, but recent data from the U.S. Centers for Disease Control and Prevention (CDC) indicate that serum levels of vitamin D decline after age 5 years, with adolescents having the lowest levels.21In some children, nutritional rickets can develop as a result of inadequate calcium intake.21

Dietary fats, preferably polyunsaturated fats, are important dietary elements in meeting a toddler’s high energy and caloric needs for growth and rapid brain development, and the AAP recommends that fats and cholesterol should not be restricted in children younger than age 2 years.3,28However, many parents restrict fat in their toddler’s diet out of concern about obesity and cardiovascular disease.3

Toddlers typically should receive about 30% of their daily calories from fat, preferably from vegetable oils, to maintain needed energy.28More specifically, the long-chain omega-3 fatty acid DHA is essential for visual, motor, and cognitive development.29DHA levels tend to decrease in late infancy and toddlerhood as cow’s milk and complementary foods replace breast milk and infant formula as sources of energy.30 

Although daily total fat intake among children aged 
18 months to 5 years does not vary considerably, toddlers aged 18 to 24 months have the lowest daily intake of DHA.31As an important component of brain lipids, DHA status is associated with cognitive development, visual acuity, and behavioral problems such as attention-deficit/hyperactivity disorder (ADHD).31,32