What is the recommended treatment for severe iron deficiency in pediatric patients?

Treatment of Severe Iron Deficiency Anemia in Pediatric Patients

For severe iron deficiency anemia in pediatric patients, oral iron supplementation at a dose of 3-6 mg/kg/day of elemental iron, given between meals, is the recommended first-line treatment. 1

Diagnosis Confirmation

Before initiating treatment, confirm iron deficiency anemia with:

• Hemoglobin <11 g/dL in children under 15 years
• Serum ferritin ≤15 μg/L (confirms iron deficiency)
• Complete blood count with red cell indices (MCV, RDW)

Treatment Options

First-Line Treatment: Oral Iron Therapy

• Dosage: 3-6 mg/kg/day of elemental iron divided into 2-3 doses 1
• Administration: Give between meals to maximize absorption
• Duration: Continue for 2-3 months total, even after hemoglobin normalizes
• Follow-up: Recheck hemoglobin after 4 weeks of therapy
  • An increase in Hb ≥1 g/dL confirms iron deficiency anemia 1
  • If no response despite compliance, evaluate for other causes

Oral Iron Formulations

1. Ferrous Sulfate:

   • Most studied and cost-effective option
   • Higher efficacy compared to other formulations 2
   • Dosage: 3-6 mg/kg/day of elemental iron

2. Ferrous Gluconate:

   • Alternative when ferrous sulfate is not tolerated
   • Similar efficacy to ferrous sulfate 3

3. Iron Bis-glycinate:

   • Good efficacy/safety profile
   • May have fewer gastrointestinal side effects 3
   • Acceptable alternative to ferrous iron preparations

Second-Line Treatment: Parenteral Iron

For patients who:

• Cannot tolerate oral iron
• Have malabsorption disorders
• Show inadequate response to oral therapy
• Have severe anemia requiring rapid correction

Parenteral Iron Options:

• Iron Sucrose (Venofer):
  • Most studied IV iron in children
  • FDA-approved for children ≥2 years in the USA 4
  • Dosage for maintenance: 0.5 mg/kg (max 100 mg) every 2-4 weeks 4
  • Severe adverse events are rare 5

Managing Side Effects of Oral Iron

Common side effects include:

• Gastrointestinal disturbances (constipation, nausea, abdominal pain)
• Black stools (expected and harmless)

Management strategies:

• Start with lower doses and gradually increase
• Consider divided doses
• Take with food if necessary (may reduce absorption but improve tolerance)
• Try different iron formulations if side effects persist

Dietary Counseling

Alongside iron supplementation:

• Limit cow's milk intake to no more than 24 oz daily 1
• Encourage iron-rich foods:
  • Lean meats, fish, poultry
  • Iron-fortified cereals and breads
  • Beans, lentils, tofu
• Promote vitamin C-rich foods with meals to enhance iron absorption 1
• For infants:
  • Use only iron-fortified formula for non-breastfed infants
  • For breastfed infants with insufficient iron from supplementary foods by age 6 months, provide 1 mg/kg/day of iron drops 1

Follow-up and Monitoring

• Recheck hemoglobin after 4 weeks of therapy
• Continue iron therapy for 2-3 months total, even after hemoglobin normalizes
• Schedule follow-up in 3-6 months to reassess iron status 1
• Monitor for potential long-term consequences of untreated iron deficiency (neurodevelopmental and cognitive deficits) 6

Special Considerations

Preterm or Low Birth Weight Infants

• Higher iron requirements: 2-4 mg/kg/day from 1 month until 12 months of age 1

Severe Anemia (Hb <7 g/dL)

• Consider hospitalization and close monitoring
• Evaluate for other causes of blood loss
• In rare cases of hemodynamic instability, blood transfusion may be considered

Patients with Chronic Kidney Disease

• May require erythropoietin therapy in addition to iron supplementation
• Higher doses of EPO may be required due to urinary losses 1

Remember that early and adequate treatment of iron deficiency anemia is crucial to prevent neurodevelopmental and cognitive deficits, which may not be fully reversible even after correction of anemia 6.