A Study on Influence of Iron on Cognition Among Pediatric Patients in Tertiary Care Teaching Hospital

Iron is an essential micronutrient required for several important physiological functions in the human body. It plays a crucial role in oxygen transport, energy metabolism, immune function, and cell growth. The average daily dietary intake of iron is about 10–15 mg, but only 1–2 mg is absorbed through the intestine. Approximately 70% of the body’s iron is present in hemoglobin within red blood cells, while the remaining iron is stored in tissues such as the liver, bone marrow, and muscles in the form of ferritin and hemosiderin. Iron exists in two forms: heme iron, which is mainly found in animal foods and is easily absorbed, and non-heme iron, which is found in plant foods and has lower absorption rates.

Iron performs several important functions in the body. It helps hemoglobin transport oxygen from the lungs to tissues and supports myoglobin in supplying oxygen to muscles. Iron also plays a role in the production of ATP (energy) through cytochrome enzymes and is necessary for DNA, RNA, and amino acid synthesis. In addition, it supports the immune system, promotes overall growth and development, and contributes to brain function, including concentration, attention, and the production of neurotransmitters such as dopamine and serotonin.

 

 

Fig 1:   Iron in blood

Iron absorption mainly occurs in the duodenum and upper jejunum of the small intestine. The efficiency of absorption depends on the form of iron and certain dietary factors. Vitamin C and animal proteins enhance iron absorption, while substances such as phytic acid, polyphenols, calcium, and oxalates can inhibit it. After absorption, iron is transported in the blood by the protein transferrin and stored primarily as ferritin. The body carefully regulates iron balance because both deficiency and excess iron can be harmful.Iron deficiency is one of the most common nutritional deficiencies worldwide and can lead to iron deficiency anemia, a condition characterized by low hemoglobin levels. According to the World Health Organization (WHO), anemia is defined as hemoglobin levels below 13 g/dL in men and 12 g/dL in women. Common symptoms include fatigue, weakness, pale skin, dizziness, shortness of breath, cold hands and feet, and increased heart rate. Iron deficiency is particularly common in children and pregnant women, where it can significantly affect growth and development.During pregnancy, the demand for iron increases due to the expansion of maternal blood volume, placental development, and fetal growth. Iron deficiency during pregnancy can lead to maternal illness, premature birth, low birth weight, and intrauterine growth restriction. It may also affect the neurological development of the fetus, resulting in long-term cognitive and behavioural problems

 

 

Fig 2:  Formation of Myelin sheath.

  Iron is necessary for the proper functioning and maturation of oligodendrocytes and for the synthesis of lipids and cholesterol that form the myelin sheath. When iron levels are insufficient, myelin production slows, leading to reduced myelinated nerve fibers and impaired nerve conduction. As a result, iron deficiency can negatively affect brain development, cognitive function, and motor skills, especially during early childhood.

 

Fig 3: Human Brain

 

Cognition refers to mental processes involved in learning, memory, reasoning, problem-solving, and decision-making. Proper brain development is essential for these cognitive abilities. Intelligence is commonly measured using Intelligence Quotient (IQ) tests, which assess an individual’s ability to acquire and apply knowledge. One widely used assessment tool for Indian children is Malin’s Intelligence Scale for Indian Children (MISIC), adapted from the Wechsler Intelligence Scale. It evaluates cognitive abilities through various verbal and performance tests such as information, arithmetic, vocabulary, digit span, block design, and picture completion.

                                                           

 

 

Fig 4: Gender wise distribution of participants

 

 

Fig 5: Age wise distribution of participants

 

 

Fig 6: IDA prevalence of the participants

 

 

Fig 7: Percentage of cognition assessment

DISCUSSION

The present study was conducted to evaluate the prevalence of iron deficiency anemia (IDA) and its association with cognitive behaviour among children. A total of 97 participants were included, with a higher proportion of males (60.8%) compared to females (39.1%). The majority of participants belonged to the age group of 12–13 years, which represents a critical stage of growth and neurodevelopment where nutritional deficiencies can significantly influence cognitive outcomes.The findings of the study revealed that 40.2% of participants had iron deficiency anemia, while 59.7% had iron deficiency without anemia. This observation is clinically important, as it indicates that iron deficiency may be present even in the absence of reduced hemoglobin levels. Similar findings have been reported in previous studies, emphasizing that iron deficiency progresses in stages, beginning with depletion of iron stores before the onset of anemia?. Therefore, relying solely on hemoglobin levels may underestimate the actual prevalence of iron deficiency.Iron is an essential micronutrient required for various physiological functions, including oxygen transport, cellular respiration, and enzymatic reactions. It is a key component of hemoglobin and plays a crucial role in maintaining adequate oxygen supply to tissues. In addition, iron is involved in mitochondrial energy production and ATP synthesis, which are vital for cellular function¹. Deficiency of iron can therefore impair multiple body systems, including the central nervous system.The cognitive assessment results in this study showed that the majority of participants were within the average range, followed by high average and extremely high categories, while only a small proportion fell into the low average category. Although most children demonstrated normal cognitive functioning, iron deficiency may still contribute to subtle cognitive impairments that are not immediately detectable through standard assessments.One of the most important roles of iron in brain development is its involvement in myelination. Myelination is the process by which axons are covered with a myelin sheath, enabling rapid transmission of nerve impulses. Oligodendrocytes, the cells responsible for myelin production in the central nervous system, require adequate iron for their maturation and function¹?. Iron deficiency has been shown to impair oligodendrocyte differentiation and reduce myelin production, leading to compromised neural communication?.Furthermore, iron is essential for the synthesis of neurotransmitters such as dopamine and serotonin, which are critical for cognitive processes including attention, memory, and learning. Disruption in neurotransmitter synthesis due to iron deficiency can lead to behavioural changes, reduced concentration, and poor academic performance. Studies have demonstrated that iron deficiency during early life can result in long-term neurodevelopmental impairments, even after iron levels are corrected?.The role of iron in myelination has been extensively studied, and it has been found that insufficient iron availability leads to decreased lipid and protein synthesis required for myelin formation¹?. This results in fewer myelinated fibers and impaired nerve conduction velocity. In addition, iron is involved in maintaining the structural integrity of myelin and supporting axonal function?. Therefore, iron deficiency can significantly affect brain connectivity and cognitive performance.Another important aspect is the role of iron metabolism in glial cells such as oligodendrocytes and astrocytes. These cells regulate iron homeostasis in the brain and are essential for proper myelination and neuronal support?. Disruption of iron metabolism in these cells can impair both myelination and remyelination processes, further contributing to cognitive deficits.The findings of this study are consistent with previous research that has established a link between iron deficiency and impaired cognitive development. Early nutrition has been shown to influence brain myelination and cognitive outcomes in children, highlighting the importance of adequate nutrient intake during critical developmental periods?. Additionally, studies have reported that poor nutritional status during infancy and childhood is associated with lower IQ scores and behavioural problems later in life¹?.Despite these associations, not all children with iron deficiency in this study showed reduced cognitive performance. This may be due to differences in the severity and duration of iron deficiency, as well as individual variability in brain development and compensatory mechanisms. Environmental factors, educational background, and socio-economic status may also influence cognitive outcomes.The study also emphasizes the importance of early detection and intervention. Advanced biomarkers such as ferritin, transferrin receptor, and iron transport proteins play a key role in assessing iron status and should be considered for accurate diagnosis¹. Improving dietary intake of iron-rich foods and enhancing absorption through dietary modifications are essential strategies for preventing iron deficiency.However, this study has certain limitations. The sample size was relatively small, and the findings may not be generalizable to a larger population. Additionally, cognitive assessment tools may not capture all dimensions of cognitive function. Further research with larger sample sizes and longitudinal follow-up is recommended to better understand the long-term effects of iron deficiency on cognitive development.Overall, the present study reinforces the critical role of iron in brain development and cognitive function. Ensuring adequate iron intake during childhood and adolescence is essential for optimal neurodevelopment and academic performance

CONCLUSION

The present study concludes that iron deficiency, with or without anemia, is a highly prevalent nutritional problem among children and adolescents and poses a significant risk to cognitive development. A considerable proportion of participants were found to have iron deficiency anemia, while an even larger number exhibited iron deficiency without anemia, indicating that early stages of deficiency may go undetected if only hemoglobin levels are assessed?. This highlights the importance of identifying iron deficiency at an early stage to prevent further complications.Iron plays a crucial role in various physiological and neurological functions, including oxygen transport, energy metabolism, and enzymatic activities. It is essential for proper brain development, particularly in processes such as myelination and neurotransmitter synthesis¹. Adequate iron levels are necessary for the functioning of oligodendrocytes, which are responsible for the formation of myelin sheaths that facilitate efficient nerve conduction¹?. Deficiency of iron can impair these processes, leading to reduced neural efficiency and compromised cognitive performance.Although most participants in this study demonstrated average cognitive performance, iron deficiency may still contribute to subtle cognitive impairments that are not immediately evident. Evidence suggests that inadequate iron levels during critical periods of brain development can lead to long-term neurodevelopmental deficits, even after correction of the deficiency?. Impaired myelination and altered neurotransmitter function due to iron deficiency can negatively affect attention, memory, learning ability, and overall intellectual performance.Furthermore, iron deficiency disrupts brain energy metabolism and reduces the synthesis of essential neurotransmitters, thereby affecting behavioural and cognitive functions¹. Studies have also shown that early nutrition plays a significant role in brain myelination and cognitive outcomes, emphasizing the importance of adequate nutrient intake during childhood?. Poor nutritional status during early life has been associated with lower IQ levels and behavioural challenges later in life¹?.The findings of this study underline the need for early screening and appropriate diagnostic measures. Reliance solely on hemoglobin levels may not be sufficient; therefore, additional biomarkers such as serum ferritin and transferrin-related parameters should be used for accurate assessment of iron status¹. Preventive strategies, including increased intake of iron-rich foods, dietary modifications to enhance iron absorption, and supplementation when necessary, are essential to reduce the burden of iron deficiency.In conclusion, maintaining adequate iron levels is vital for both physical health and optimal cognitive development in children. Early identification and timely intervention can help prevent long-term neurocognitive impairments and improve overall developmental outcomes. Public health strategies focusing on nutrition education, routine screening, and effective management are essential to address this widespread issue and promote better health and cognitive well-being among children.

CLINICAL PHARMACIST INTERCESSION:

In our study, we provide awareness about the importance of iron, what are the health issues causes due to iron deficiency, what are the foods taken to improve iron level in the body and also to endure the iron absorption, how much iron required in the daily diet as per guidelines given by WHO and CDC.Also provide awareness about the responsibility of pregnant women to take care during pregnancy period about iron range in the body, and to the lactating women, those who are with participants included in this study to take iron-rich food items because the study done by Wenfang Yang et al. suggested that babies who took breastfeeding by anemic mothers are prone to get IDA.

LIMITATION:

• This study was limited in the pediatrics patients between the age group 6 yearold to 15year 11month old.
• The number of participants obtained and the study duration were limited. If the study was conducted for long duration, more significant results may have been obtained.
• The study was limited to Department of Pediatrics in-ward department.

REFERENCES

1. Piskin E, Cianciosi D, Gulec S, Tomas M, Capanoglu E. Iron Absorption: Factors, Limitations, and Improvement Methods. ACS Omega. 2022 Jun 10;7(24):20441-20456. doi: 10.1021/acsomega.2c01833. PMID: 35755397; PMCID: PMC9219084.
2. Santiago González DA, Cheli VT, Wan R, Paez PM. Iron Metabolism in the Peripheral Nervous System: The Role of DMT1, Ferritin, and Transferrin Receptor in Schwann Cell Maturation and Myelination. J Neurosci. 2019 Dec 11;39(50):9940-9953. doi: 10.1523/JNEUROSCI.1409-19.2019. Epub 2019 Nov 1. PMID: 31676601; PMCID: PMC6978953.
3. Kumar G, Meena G, Bhati BL. To Correlation between Iron Profile of Pregnant Women and Their Newborns: A Cross Sectional Study. Asian J. Med. Res. 2019;8(3):PE01-PE03.DOI: dx.doi.org/10.21276/ajmr.2019.8.3.PE1
4. Georgieff MK. Iron deficiency in pregnancy. Am J Obstet Gynecol. 2020 Oct;223(4):516-524. doi:          10.1016/j.ajog.2020.03.006. Epub 2020 Mar 14. PMID: 32184147; PMCID: PMC7492370.
5. Ozdemir N. Iron deficiency anemia from diagnosis to treatment in children. Turk Pediatri Ars. 2015 Mar 1;50(1):11-9. doi: 10.5152/tpa.2015.2337. PMID: 26078692; PMCID: PMC4462328.                  
6. Deoni S, Dean D 3rd, Joelson S, O'Regan J, Schneider N. Early nutrition influences developmental myelination and cognition in infants and young children. Neuroimage. 2018 Sep;178:649-659. doi: 10.1016/j.neuroimage.2017.12.056. Epub 2017 Dec 20. PMID: 29277402; PMCID: PMC6540800.
7. illiamson JM, Lyons DA. Myelin Dynamics Throughout Life: An Ever-Changing Landscape? Front Cell Neurosci. 2018 Nov 19;12:424. doi: 10.3389/fncel.2018.00424. PMID: 30510502; PMCID: PMC6252314.
8. Simons M, Nave KA. Oligodendrocytes: Myelination and Axonal Support. Cold Spring Harb Perspect Biol. 2015 Jun 22;8(1):a020479. doi: 10.1101/cshperspect.a020479. PMID: 26101081; PMCID: PMC4691794.
9. Cheli VT, Correale J, Paez PM, Pasquini JM. Iron Metabolism in Oligodendrocytes and Astrocytes, Implications for Myelination and Remyelination. ASN Neuro. 2020 Jan-Dec;12:1759091420962681. doi: 10.1177/1759091420962681. PMID: 32993319; PMCID: PMC7545512.
10. Todorich B, Pasquini JM, Garcia CI, Paez PM, Connor JR. Oligodendrocytes and myelination: the role of iron. Glia. 2009 Apr 1;57(5):467-78. doi: 10.1002/glia.20784. PMID: 18837051.
11. mesh M, Singaravelu V, Kalpana M, Ganji V, Gaur A, Taranikanti M, John NA. Cognitive skills assessment in deaf and hard of hearing school children. J Family Med Prim Care. 2025 Mar;14(3):874-879. doi: 10.4103/jfmpc.jfmpc_1239_24. Epub 2025 Mar 25. PMID: 40256057; PMCID: PMC12007772.
12. Sansone SM, Schneider A, Bickel E, Berry-Kravis E, Prescott C, Hessl D. Improving IQ measurement in intellectual disabilities using true deviation from population norms. J Neurodev Disord. 2014;6(1):16. doi: 10.1186/1866-1955-6-16. Epub 2014 Jul 8. PMID: 26491488; PMCID: PMC4613563.
13. Sharma S, Balsavar A, Beniwal RP, Bhatia T, Deshpande SN. A Pilot Study of Correlation between Intelligence Quotient, Social Quotient, and Ayurveda Parameters in Children. Indian J Psychol Med. 2018 Jan-Feb;40(1):74-79. doi: 10.4103/IJPSYM.IJPSYM_227_17. PMID: 29403134; PMCID: PMC5795683.
14. Lozoff B, Georgieff MK. Iron deficiency and brain development. Semin Pediatr Neurol. 2006;13(3):158–165.
15. Smithers LG, Lynch JW, Yang S, Dahhou M, Kramer MS. Impact of neonatal growth on IQ and behavior at early school age. Pediatrics. 2013 Jul;132(1):e53-60. doi: 10.1542/peds.2012-3497. Epub 2013 Jun 17. PMID: 23776123; PMCID: PMC4530288.
16. Gutema BT, Sorrie MB, Megersa ND, Yesera GE, Yeshitila YG, Pauwels NS, De Henauw S, Abbeddou S. Effects of iron supplementation on cognitive development in school-age children: Systematic review and meta-analysis. PLoS One. 2023 Jun 27;18(6):e0287703. doi: 10.1371/journal.pone.0287703. PMID: 37368919; PMCID: PMC10298800.
17. Beard JL. Iron deficiency alters brain development and functioning. J Nutr. 2003;133(5):1468S–1472S.
18. Wang M. Iron Deficiency and Other Types of Anemia in Infants and Children. Am Fam Physician. 2016 Feb 15;93(4):270-8. PMID: 26926814
19. Jha N. Pooja & Gorthi V.N Gayatri (2021). Intellectual Profile of Children with Specific Learning Disability with and without ADHD on Mallin’s Intelligence Scale for Indian Children (MISIC). International Journal of Indian Psychology, 9(4), 615-627. DIP:18.01.059.20210904, DOI:10.25215/0904.059
20. World Health Organization. Iron deficiency anaemia: assessment, prevention and control. Geneva: WHO; 2001                               
21. https://www.guidetopharmacology.org/links.jsp
22. https://www.who.int
23. https://www.ncbi.nlm.nih.gov/books/NBK518755/
24. Topic  - cognitive science
25. Author- Jay friedenberg , Gordon silverman
26. Friedenberg J, Silverman G. Cognitive approach. In: Cognitive science: an introduction to the study of mind. Thousand Oaks: Sage Publications; p. 125–154.
27. Galotti KM. Problem solving and general knowledge. In: Cognitive psychology in and out of the laboratory. 4th ed. Belmont (CA): Wadsworth; 2008. p. 234, 386.
28. Alosco ML, Stern RA. Neurocognition. In: The Oxford handbook of adult cognitive disorders. Oxford: Oxford University Press; p. 249.
29. Bose SC. Cognition information processing. In: Psychology of development and learning. Vol. 2. New Delhi: [Publisher not specified]; p. 100–158.