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Eur J Pediatr (2012) 171:143–146
DOI 10.1007/s00431-011-1506-6
ORIGINAL PAPER
Ferritin and iron levels in children with autistic disorder
Sabri Hergüner & Fatih Mehmet Keleşoğlu &
Cansaran Tanıdır & Mazlum Çöpür
Received: 26 March 2011 / Accepted: 25 May 2011 / Published online: 4 June 2011
# Springer-Verlag 2011
Abstract Iron has an important role on cognitive, behavioral,
and motor development. High prevalence of iron deficiency
has been reported in autism. The aim of this study was to
investigate iron status in a group of children with autistic
disorder. The sample was composed of 116 children between
3 and 16 years with a diagnosis of autistic disorder according
to DSM-IV criteria. Serum ferritin, iron, hemoglobin,
hematocrit, mean corpuscular volume, and red cell distribu-
tion width values were measured. We found that 24.1% of
subjects had iron deficiency, and 15.5% had anemia. There
was a significant positive correlation between age and ferritin
and hematological measures. Results of this study confirmed
This study is presented as a poster presentation in the International
Meeting for Autism Research (IMFAR) 2010, Philadelphia.
S. Hergüner
Department of Child and Adolescent Psychiatry,
Meram Faculty of Medicine, Selcuk University,
Konya, Turkey
S. Hergüner : M. Çöpür
Clinic of Child and Adolescent Psychiatry, Bakırköy State
Hospital for Mental Health and Neurological Disorders,
Istanbul, Turkey
F. M. Keleşoğlu
Department of Pediatrics,
Istanbul Faculty of Medicine, Istanbul University,
Istanbul, Turkey
C. Tanıdır
Clinic of Pediatrics, Okmeydanı State Hospital,
Istanbul, Turkey
S. Hergüner (*)
Cocuk ve Ergen Psikiyatrisi AD, Meram Tip Fakultesi,
Konya, Turkey
e-mail: cocukergen@yahoo.com
that iron deficiency and anemia are common in children with
autistic disorder. Conclusion: These findings suggest that
ferritin levels should be measured in subjects with autism as
a part of routine investigation.
Keywords Autism . Children . Ferritin . Iron deficiency .
Anemia
Introduction
Autism is a neurodevelopmental disorder characterized
by qualitative impairments in social interaction, and
verbal and non-verbal communication, along with re-
stricted, stereotyped interests and behaviors [1]. The
disorder is accompanied by mental retardation in three
out of four patients, and boys are four times more likely
than girls to receive the diagnosis. The underlying etiology
is not known clearly; however, it is suggested that autism
most likely results from the interaction of multiple genetic
and environmental factors [22].
There is considerable evidence about the important role
of iron on cognitive, behavioral, and motor development
[3]. It is a component of many enzymes involved in
neurotransmitter synthesis, and in iron deficiency, due to
decreased activity of associated enzymes, monoamine
neurotransmitter systems may be affected [21]. A decrease
in brain iron concentration is accompanied by changes in
serotonergic and dopaminergic systems, in cortical fiber
conduction, and myelogenesis [10].
Serum ferritin is the most widely used marker of iron
stores in body tissues, including the brain. Low levels are a
sign of iron deficiency and an early precursor of iron
deficiency anemia. It declines before serum iron when iron
stores are depleted and exhibits less variability than serum
144
iron [12]. Some studies reported that subjects with
Tourette's syndrome (TS), attention deficit hyperactivity
disorder (ADHD), and restless legs syndrome (RLS) had
lower ferritin levels than healthy controls [11, 18, 19]. It
was speculated that iron deficiency might contribute to the
pathophysiology of TS, ADHD, and RLS via its impact on
the dopaminergic system [6].
High prevalence of iron deficiency has also been
reported in children with autism spectrum disorders [4, 8,
20]. Inadequate dietary iron intake was considered as a
cause of iron deficiency, and low iron intake was thought to
be associated with food selectivity which is commonly seen
in children with autistic disorder (AD) [5, 13, 14, 24]. It
was also shown that serum ferritin returned to normal level
after iron supplementation [9].
The aim of this study was to investigate the iron status
and hematological measures of Turkish children with AD in
a clinic-referred sample.
Materials and methods
Sample
The study group included children who met Diagnostic
and Statistical Manual of Mental Disorders, Fourth
Edition diagnostic criteria for AD [1]. All cases were
recruited from the Child Psychiatry Out-Patient Clinic in
Bakırköy State Hospital for Mental Health and Neurological
Disorders between May 2008 and April 2009. The clinical
assessment of subjects was made by two experienced child
psychiatrists (SH, MC). Since ferritin is a marker of
inflammation, children with infection or other inflammatory
conditions were excluded from the study. Children who had
received iron supplementation in the past 3 months and who
were on any dietary restrictions were also excluded. The
protocol of this study was approved by the ethical committee
of the hospital. Informed consent was obtained from the
parents of all children.
Laboratory measurements
There is no consensus in the literature about the cutoff
value for low serum ferritin in children [7]. We used ferritin
cutoff of <10 ng/mL for preschoolers and <12 ng/mL for
school-aged children to estimate iron deficiency since this
was a widely used criterion in previous studies [8, 20].
Anemia was defined as hemoglobin <11.0 g/dL for
preschoolers and <12.0 g/dL for school-aged children.
The following cutoffs were used based on our hospital
laboratory values: iron, <45 μg/dL; hematocrit, <35%;
mean corpuscular volume (MCV), <80 fL; and red cell
distribution width (RDW), >14.5%.
Eur J Pediatr (2012) 171:143–146
Ferritin, iron, hemoglobin, hematocrit, MCV, and
RDW values were measured in fasting blood in the
morning at the Bakırköy State Hospital for Mental
Health and Neurological Disorders Chemistry Laboratory
using standard measurement assays. All subjects with
iron deficiency or anemia were referred to pediatricians
for treatment.
Statistical analysis
Data were analyzed using SPSS 16.0 software (SPSS, Inc.,
Chicago, IL, USA). Demographic and clinical data were
shown as means and SD or percentages. Categorical
variables were compared between preschoolers (age
<6 years) and school-aged children (age ≥6 years) by using
chi-square test. Student's t test was used to compare
continuous variables. Pearson's correlation analysis was
performed to examine the correlations between age and
ferritin, iron, and hematological measures. A probability
level of p<.05 was used to indicate statistical significance.
Two-tailed significance values are reported throughout.
Results
The sample consisted of 116 children (95 boys, 21 girls)
between 3 and 16 (mean±SD=8.5±3.6) years. The study
group was divided into two groups as group 1, cases
<6 years old (n=37), and group 2, cases ≥6 years old (n=
79). Table 1 shows demographic characteristics of the
subjects.
The mean ± SD of laboratory measures, including
ferritin, iron, and hematological values, are summarized in
Table 2. Ferritin, iron, hemoglobin, hematocrit, and MCV
were significantly lower, and RDW was significantly higher
in group 1. There were positive correlations between age
and ferritin, hemoglobin, hematocrit, and MCV levels
(Table 3). There was no difference between males and
females in all measures (data not shown).
Twenty-seven (24.1%) subjects had iron deficiency, and
18 (15.5%) had anemia. Iron deficiency was more prevalent
in preschool-aged than school-aged children (32.4% vs.
Table 1 Demographic characteristics
Total <6 years >6 years
n=116 n=37 n=79
Age, years
Mean ± SD 8.51±3.66 4.64±0.95 10.32±2.98
Gender, n (%)
Male 95 (81.9%) 31 (83.8%) 64 (81.0%)
Female 21 (18.1%) 6 (16.2%) 15 (19.0%)
Eur J Pediatr (2012) 171:143–146 145

Table 2 Ferritin, iron, and

hematological values Total <6 years >6 years p Value
n=116 n=37 n=79

Ferritin (ng/mL) 25.95±19.70 20.21±14.89 28.64±21.13 .015

Iron (μg/dL) 73.38±32.69 64.91±27.82 77.35±34.18 .040
Hemoglobin (g/dL) 12.80±1.27 12.14±1.10 13.11±1.24 .000
Hematocrit (%) 38.13±3.21 36.23±2.62 39.02±3.08 .000
MCV (fL) 78.93±5.89 76.14±5.74 80.24±5.53 .000
MCV mean corpuscular volume, RDW (%) 14.04±1.50 14.64±1.91 13.83±1.27 .016
RDW red cell distribution width

20.3%), but this was not significant (Table 4). However, southeast region of Turkey, Şanlıurfa. In our sample, 24.1% of
there was a negative correlation between age and iron children with autism had iron deficiency, and 15.5% had
deficiency prevalence (r=−.182, p=.05). anemia which suggest that children with AD are under risk for
iron deficiency and anemia.
The reason for low ferritin levels in children with autism is
Discussion unclear. Autism and iron deficiency could be linked by a
common underlying genetic mechanism that has not been
In this study, we found that 24.1% of children with AD had identified yet. Alternatively, because iron is involved in brain
iron deficiency, and 15.5% had anemia. Our findings monoamine systems including serotonin, dopamine, and
confirmed that iron deficiency and anemia are common in noradrenaline [21] and the likely involvement of these
autism, in parallel with previous reports [4, 8, 20]. systems in autism suggest that iron may influence autism
In the literature, there are three studies investigating iron through its effects on monoamine-dependent neurotransmis-
status in children with autism. In South Wales [20], a sion. A correlation between ferritin levels and communica-
routine blood investigation showed high prevalence of iron tion impairment was reported [8]; however, Bilgic et al. [4]
deficiency (52%). A study from Canada [8] reported that found no association between iron deficiency and severity of
ferritin level was low in 8.3% of 1–2-year-old children, in autistic symptoms. As gastrointestinal symptoms are frequent
14.2% of 3–5-year-olds and in 20% of 6–10-year-olds. in children with autism [23], impaired absorption might be
Different from the results of this study, iron deficiency was another possible cause of iron deficiency. However, Dosman
higher in preschoolers than school-aged children in our et al. [9] reported that ferritin and iron levels increased after
sample. Finally, Bilgic et al. [4] demonstrated that one third iron supplementation which excludes the probability of
of Turkish preschool children with autism spectrum disorders malabsorption.
had iron deficiency which is similar with our findings. Finally, as it is the case for most iron-deficient children
Results of limited studies conducted in different cities in the general population [16], iron deficiency in autism
within Turkey showed that iron deficiency is an important may be a result of reduced dietary iron intake. Children
health care problem [2, 15, 17]. Aydinok et al. [2] found with autism often have very restricted food preferences due
that the prevalence of iron deficiency was 6.5% in to smell, taste, texture, or other characteristics of the foods
adolescents living in the west region of Turkey, Izmir.
Among schoolchildren living in the three largest cities Table 4 Prevalence of anemia and iron deficiency
(Istanbul, Ankara, Izmir) of Turkey, prevalence of iron
Total <6 years >6 years p Value
deficiency (ferritin <15 mg/l) and iron deficiency anemia n=116 n=37 n=79
was 19.1% and 3.9%, respectively [15]. Koc et al. [17]
demonstrated that the prevalence of anemia among school- Anemia 18 (15.5%) 5 (13.5%)a 13 (16.5%)b .680
aged children was 5%, and iron deficiency was 5.45% in the Iron deficiency 28 (24.1%) 12 (32.4%)c 16 (20.3%)d .160
Iron<45 μg/dL 27 (23.3%) 11 (29.7%) 16 (20.3%) .267
Table 3 Correlation between age and ferritin, iron and hematological Hematocrit<35% 20 (17.2%) 12 (32.4%) 8 (10.1%) .004
values MCV<80 fL 58 (50.0%) 26 (70.3%) 32 (40.5%) .003
RDW>14.5% 27 (23.2%) 13 (35.1%) 14 (17.7%) .062
Ferritin Iron Hemoglobin Hematocrit MCV RDW
MCV mean corpuscular volume, RDW red cell distribution width
Age a
Hemoglobin<11.0 g/dL
r .193 .073 .466 .574 .388 −.146 b
Hemoglobin<12.0 g/dL
p .038 .436 .000 .000 .000 .148 c
Ferritin<10 ng/mL
MCV mean corpuscular volume, RDW red cell distribution width d
Ferritin<12 ng/mL
146
[5]. Several studies [13, 14, 24] showed that nearly half of
children with autism had inadequate dietary iron intake.
Additionally, Dosman et al. [9] reported that twice as many
preschoolers (69%) than school-aged children (35%) had
insufficient dietary iron intake. Also, Xia et al. [24] found
that intake of iron increased with age in 2- to 9-year-old
children with autism. One fourth of our group had iron
deficiency, and this was even higher in preschoolers.
Because younger children with autism are more selective
about what they eat, iron deficiency may be more prevalent
in this age group.
The results of this study must be considered within the
context of its limitations. The first issue is lack of a control
group. Second, as the most common cause of iron deficiency
is inadequate iron intake, we did not use a food survey to
record the diet of children. Finally, we did not use any
instrument to evaluate the severity of autistic symptoms.
Conclusion
As screening subjects at risk for iron deficiency is
recommended, results of this study suggest that serum
ferritin levels should be measured in every case with autism
as a part of routine investigation. Further studies are needed
to better understand the role of iron in autism.
Disclosure The authors do not have any actual or potential conflict
of interest including any financial, personal, or other relationships
with other people or organizations.
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