What are the symptoms and treatment options for children with low ferritin (iron) levels?

Symptoms and Treatment of Low Ferritin in Children

Children with low ferritin levels primarily present with symptoms of fatigue, irritability, decreased attention span, and poor cognitive performance, which should be treated with oral iron supplementation at a dose of 3-6 mg/kg of elemental iron daily to prevent long-term neurodevelopmental deficits. 1

Clinical Presentation of Low Ferritin in Children

Low serum ferritin is the most specific indicator of depleted iron stores and an early marker of iron deficiency, even before anemia develops 2. Children with low ferritin may present with:

Common Symptoms:

• Pallor (most frequent presenting feature) 1
• Excessive sleepiness/fatigue 3
• Irritability or inappropriate behavior 3
• Decreased attention span 3
• Learning disabilities 3
• Poor cognitive performance 4
• Behavioral issues (particularly hyperactivity) 4

Advanced Symptoms (when progressing to iron deficiency anemia):

• Tachycardia
• Shortness of breath
• Poor capillary refill
• Exercise intolerance 1
• Pica (eating non-food substances) 3

Important Consideration:

Low ferritin in early childhood, especially if severe and prolonged, can result in neurodevelopmental and cognitive deficits that may not be fully reversible even after correction of iron deficiency 1.

Diagnostic Approach

Laboratory Assessment:

• Serum ferritin < 15 μg/L confirms iron deficiency with high specificity (98%) 2
• Recent evidence suggests raising the diagnostic threshold to 24-25 μg/L for one-year-old children 5
• Complete blood count to assess for:
  • Low hemoglobin (<110 g/L in one-year-olds)
  • Microcytosis (low MCV)
  • Hypochromia
  • Elevated RDW (>14.0%) - indicates iron deficiency anemia 2

Differential Diagnosis:

• Thalassemia minor (typically has low MCV but normal RDW ≤14.0%) 2
• Chronic inflammation (may have falsely elevated ferritin despite iron deficiency) 2
• Lead poisoning (can present with similar symptoms) 2

Treatment Approach

First-line Treatment:

• Oral iron supplementation is the treatment of choice 1
• Dosage: 3-6 mg/kg of elemental iron per day 1
• Ferrous sulfate is the most cost-effective preparation 1
  • Each tablet contains 324 mg ferrous sulfate = 65 mg elemental iron 6
  • Pediatric formulations are available

Administration Tips:

• Divide into 1-3 doses per day
• Administer between meals or at bedtime for better absorption
• Do not administer with milk or calcium-rich foods
• Do not administer within 2 hours of tetracycline antibiotics 6
• Consider vitamin C co-administration to enhance absorption

Monitoring Response:

• Expect reticulocytosis within 3-5 days
• Hemoglobin should rise by 1 g/dL after 2-4 weeks
• Continue treatment for 2-3 months after normalization of hemoglobin to replenish iron stores

Side Effects and Management:

• Gastrointestinal discomfort, nausea, constipation, or diarrhea are common 6
• If side effects occur, consider:
  • Reducing dose temporarily
  • Taking with small amounts of food
  • Switching to a different iron preparation

Special Situations:

• Parenteral iron therapy is rarely necessary in children
• Blood transfusion is generally not required unless severe symptomatic anemia is present 1

Prevention Strategies

Primary Prevention:

• Iron-rich diet (meat, fish, poultry, fortified cereals)
• Iron supplementation for high-risk infants
• The American Academy of Pediatrics recommends universal screening for iron deficiency anemia at approximately one year of age 1

Risk Factors to Address:

• Prematurity
• Exclusive breastfeeding beyond 4-6 months without iron supplementation
• Early introduction of cow's milk (before 12 months)
• Low socioeconomic status
• Poor dietary intake of iron-rich foods

Clinical Pitfalls to Avoid

1. Misinterpreting ferritin levels during infection/inflammation - Ferritin is an acute-phase reactant and may be falsely elevated during infection or inflammation 2

2. Undertreating the duration - Continuing iron therapy only until hemoglobin normalizes without replenishing stores

3. Overlooking non-dietary causes - Blood loss (e.g., occult GI bleeding) should be considered in persistent cases

4. Ignoring cognitive/behavioral symptoms - Low ferritin can affect behavior and cognition even before anemia develops 4

5. Using inappropriate ferritin thresholds - Traditional cutoffs may miss iron deficiency; newer evidence suggests higher thresholds may be appropriate for screening 5