Severe Iron Deficiency Anemia and Growth Faltering Associated With Excessive Cow’s Milk Intake and Possible Celiac Disease in Indian Children: A Case Series

Cow's milk is widely considered a fundamental component of early childhood nutrition in India and frequently represents the primary daily beverage for toddlers. However, cow's milk contains minimal bioavailable iron and may inhibit intestinal iron absorption, thereby increasing the risk of iron deficiency. Iron deficiency remains the most prevalent micronutrient deficiency in India and is the leading cause of anemia among young children. Despite national nutrition initiatives, anemia prevalence in this age group continues to be substantial, largely driven by inadequate dietary iron intake, prolonged milk-dominant feeding, suboptimal complementary feeding practices, and socioeconomic determinants. In urban and semi-urban Indian populations, excessive cow's milk consumption has emerged as a clinically relevant yet frequently overlooked contributor to iron deficiency in toddlers. In addition to its low iron content, high intake of cow's milk may impair iron utilization and predispose children to occult gastrointestinal blood loss. We describe five Indian children (age range: 48-84 months) presenting with severe iron deficiency anemia (IDA) associated with high daily intake of cow's milk (≥600 to 1,000 mL) and inadequate consumption of iron-rich complementary foods. All patients presented with marked pallor and lethargy. Three children had poor weight gain, while two demonstrated tachycardia with clinical features suggestive of early cardiac decompensation. Hematologic investigations revealed severe microcytic hypochromic anemia with markedly reduced serum ferritin and elevated total iron-binding capacity. Three children required hospital admission, and one required pediatric intensive care unit management with packed red blood cell transfusion due to hemodynamic instability. Management included blood transfusion when clinically indicated, therapeutic oral iron supplementation, dietary modification, and restriction of cow's milk intake to age-appropriate levels. Follow-up at 8-12 weeks demonstrated substantial hematologic recovery in all cases. This case series highlights the ongoing burden of nutritional IDA among Indian toddlers and underscores the importance of caregiver education, routine dietary assessment during pediatric visits, and counseling on appropriate milk intake to prevent severe anemia and its complications.