What is the recommended dose of iron salts, specifically ferrous (iron) sulfate, for pediatric patients with iron deficiency anemia?

Pediatric Iron Supplementation for Iron Deficiency Anemia

The recommended dose of ferrous sulfate for pediatric iron deficiency anemia is 3-6 mg/kg/day of elemental iron divided into 1-3 doses, with a maximum daily dose typically not exceeding 200 mg of elemental iron. 1

Age-Specific Dosing Recommendations

Infants and Young Children

• Preterm infants: 2-4 mg/kg/day of elemental iron 1
• Term infants to 3 years: 3 mg/kg/day of elemental iron 2, 1
• Children 3-12 months: Can be given as a single daily dose of elemental iron 3

Older Children and Adolescents

• School-age children (5-12 years): 60 mg elemental iron daily 2, 1
• Adolescent boys: 120 mg elemental iron daily 2, 1
• Adolescent girls: 60-120 mg elemental iron daily 1

Iron Preparations and Elemental Iron Content

Different iron salt preparations contain varying amounts of elemental iron:

Iron Preparation	Tablet Size (mg)	Elemental Iron Content (mg)
Ferrous sulfate	325	65
Ferrous fumarate	325	108
Ferrous gluconate	325	35
Iron polysaccharide	-	150

Administration Guidelines

• Timing: Administer between meals or on an empty stomach for optimal absorption 1

  • Food can reduce iron absorption by up to 50% if eaten within 2 hours before or 1 hour after an iron supplement
  • If gastrointestinal side effects occur, iron can be taken with meals, though absorption will be reduced

• Duration of therapy:

  • Initial treatment for at least 4 weeks 1
  • Continue therapy for 2-3 months after normalization of hemoglobin to replenish iron stores 1
  • Reassess hemoglobin approximately 6 months after successful treatment 2, 1

Monitoring Response to Treatment

• After 4 weeks: Repeat hemoglobin or hematocrit 2, 1

  • An increase in hemoglobin ≥1 g/dL or hematocrit ≥3% confirms iron deficiency anemia 2
  • If confirmed, continue iron treatment for 2 more months 2

• If no response after 4 weeks: Further evaluate with additional laboratory tests including MCV, RDW, and serum ferritin 2

  • Serum ferritin <15 μg/L confirms iron deficiency
  • Serum ferritin >15 μg/L suggests another cause of anemia

Evidence-Based Considerations

• Ferrous sulfate vs. iron polysaccharide complex: Research shows ferrous sulfate is more effective than iron polysaccharide complex in increasing hemoglobin levels in children with iron deficiency anemia 4

  • A randomized clinical trial showed a greater increase in hemoglobin (1.0 g/dL higher) with ferrous sulfate compared to iron polysaccharide complex 4
  • Higher rates of complete resolution of iron deficiency anemia were observed with ferrous sulfate (29% vs. 6%) 4

• Dosing frequency: Once-daily dosing may be as effective as multiple daily doses 3

  • A randomized controlled trial showed similar rates of successful treatment of anemia with once-daily versus three-times-daily ferrous sulfate drops at the same total daily dose 3
  • Single daily dosing may improve adherence to treatment

Common Side Effects and Management

• Gastrointestinal effects: Nausea, constipation, abdominal discomfort
• Management strategies:
  • Start with lower doses and gradually increase
  • Divide into smaller, more frequent doses
  • Try different iron formulations
  • Consider taking at bedtime

Important Caveats

• Children consuming more than 24 oz of cow's milk daily are at higher risk for iron deficiency and require careful monitoring 1
• Liquid iron preparations can stain teeth; administer with a dropper or straw and rinse mouth afterward
• Store iron supplements out of reach of children to prevent accidental overdose, which can be fatal
• For patients unable to tolerate oral iron or with severe anemia, parenteral iron may be considered, with iron sucrose being the most studied and safest option for children 2

I hope this helps!