What is the first-line treatment for iron deficiency anemia in pediatric patients?

First-Line Treatment for Iron Deficiency Anemia in Pediatric Patients

The first-line treatment for iron deficiency anemia in pediatric patients is oral iron supplementation at a dose of 3 mg/kg per day of elemental iron, administered between meals. 1

Diagnosis and Evaluation

Before initiating treatment, confirm the diagnosis with:

• Hemoglobin/hematocrit levels
• Peripheral blood smear (showing hypochromia, microcytosis, and anisocytosis)
• Serum ferritin (the most specific test for iron deficiency)

Risk factors requiring screening include:

• Preterm or low-birthweight infants
• Infants fed non-iron-fortified formula for >2 months
• Infants introduced to cow's milk before age 12 months
• Breastfed infants with inadequate iron from supplementary foods after 6 months
• Children consuming >24 oz daily of cow's milk
• Children with special healthcare needs

Treatment Algorithm

1. Oral Iron Therapy

• Dosage: 3-6 mg/kg/day of elemental iron 1, 2
• Formulation: Ferrous sulfate (most common and cost-effective)
  • Each tablet contains 324 mg ferrous sulfate = 65 mg elemental iron 3
• Administration: Give between meals to maximize absorption
• Duration: Continue for 2-3 months after hemoglobin normalizes to replenish iron stores

2. Monitoring Response

• Recheck hemoglobin after 4 weeks of treatment
• An increase in hemoglobin ≥1 g/dL confirms the diagnosis of iron deficiency anemia
• Continue iron for 2 additional months after hemoglobin normalizes
• Reassess hemoglobin approximately 6 months after successful treatment 1

3. When to Consider IV Iron

Consider intravenous iron only in specific situations:

• Poor adherence to oral iron therapy
• Intolerance to oral iron (significant gastrointestinal side effects)
• Malabsorption disorders
• Severe anemia requiring rapid correction 4

Dietary Recommendations

In addition to iron supplementation:

• For infants 4-6 months: Introduce iron-fortified infant cereal (two or more servings daily)
• By 6 months: Include foods rich in vitamin C with meals to enhance iron absorption
• After 6 months: Introduce pureed meats when developmentally appropriate
• For children 1-5 years: Limit cow's milk, goat's milk, or soy milk to no more than 24 oz daily 1

Common Pitfalls and Caveats

1. Inadequate dosing: Ensure proper calculation of elemental iron dose (not just the salt weight)
2. Poor adherence: Oral iron can cause gastrointestinal side effects (constipation, nausea, black stools) that reduce compliance; consider alternate-day dosing to improve tolerability
3. Premature discontinuation: Treatment should continue for 2-3 months after hemoglobin normalizes to replenish iron stores
4. Failure to address underlying cause: Investigate and treat the cause of iron deficiency (poor diet, blood loss, malabsorption)
5. Overuse of cow's milk: Excessive cow's milk consumption (>24 oz/day) can contribute to iron deficiency

If after 4 weeks the anemia does not respond to iron treatment despite compliance, further evaluate with additional laboratory tests, including MCV, RDW, and serum ferritin concentration to confirm the diagnosis and consider other causes of anemia 1.