What are the guidelines for iron supplementation in children with iron deficiency or insufficiency?

Guidelines for Iron Supplementation in Children with Iron Deficiency or Insufficiency

Iron supplementation in children should be guided by iron status assessment, with oral iron as the preferred route for most children, administered at age-specific doses, and continued for 3 months after normalization of hemoglobin levels. 1, 2

Diagnosis and Assessment

• Screening recommendations:

  • Universal screening for high-risk populations (low-income families, WIC-eligible children, migrants, refugees) at 9-12 months, 6 months later, and annually from ages 2-5 years 1
  • Selective screening for children with risk factors:
    • Preterm or low-birthweight infants
    • Non-iron-fortified formula feeding >2 months
    • Cow's milk introduction before 12 months
    • Inadequate iron intake in breast-fed infants after 6 months
    • Consumption of >24 oz daily of cow's milk
    • Special health-care needs 1

• Diagnostic criteria:

  • Ferritin <30 μg/L: Definitive iron deficiency
  • Transferrin saturation <16%: Diagnostic of iron deficiency regardless of ferritin
  • Ferritin 30-100 μg/L with transferrin saturation <20%: Possible iron deficiency, especially with inflammation 2

Treatment Recommendations

Oral Iron Supplementation

• Dosage by age group:

  • Infants with iron deficiency anemia: 3 mg/kg/day of elemental iron 1
  • Preterm or low-birthweight infants: 2-4 mg/kg/day (maximum 15 mg/day) starting at 1 month after birth until 12 months 1
  • Breast-fed infants with insufficient iron from supplementary foods: 1 mg/kg/day of iron drops 1
  • Children (1-18 years): 50-100 μg/kg/day up to maximum of 5 mg/day 1

• Administration guidelines:

  • Give between meals to maximize absorption 1
  • Consider administering with vitamin C to enhance absorption 2
  • Avoid administration with tea, coffee, calcium supplements, or high-fiber foods 2
  • Continue treatment for 3 months after hemoglobin normalization to replenish iron stores 2

Parenteral Iron

• Indications:

  • Long-term parenteral nutrition when enteral iron supplementation is insufficient 1
  • Active inflammation in conditions affecting iron absorption 2

• Dosage:

  • Preterm infants: 200-250 μg/kg/day
  • Term infants to 3 months: 50-100 μg/kg/day
  • Children >3 months: 50-100 μg/kg/day (maximum 5 mg/day) 1

• Preferred formulations:

  • Iron sucrose is most studied in children with few adverse events 1
  • Avoid iron dextran due to higher risk of allergic reactions 1

Preventive Strategies

• Dietary recommendations:
  • For infants <12 months not exclusively breast-fed: use only iron-fortified formula 1
  • Introduce iron-fortified infant cereal at 4-6 months (2+ servings/day) 1
  • Include vitamin C-rich foods with meals by 6 months to improve iron absorption 1
  • Introduce pureed meats after 6 months 1
  • Limit cow's milk, goat's milk, or soy milk to no more than 24 oz daily for children 1-5 years 1

Monitoring

• Follow-up schedule:
  • Monitor hemoglobin response within 4 weeks of starting therapy 2
  • Check positive anemia screening with repeat hemoglobin or hematocrit test 1
  • Regular monitoring of iron status (ferritin and hemoglobin) for patients on long-term treatment 1, 2
  • Target ferritin >100 μg/L to ensure adequate iron stores 2

Cautions and Considerations

• Potential adverse effects:

  • Excessive iron supplementation in iron-replete children may have adverse effects on growth, infection risk, and cognitive development 3, 4
  • In malarious regions, iron supplementation may increase risk of infections in iron-replete children 5
  • Iron supplementation should be targeted to those with confirmed deficiency in areas with low prevalence of iron deficiency 3

• Special populations:

  • Children with inflammatory conditions may have falsely elevated ferritin levels 2
  • Children with high gastrointestinal fluid losses may have significantly higher iron requirements 1

Iron deficiency anemia in early childhood, especially if severe and prolonged, can result in neurodevelopmental and cognitive deficits that may not be fully reversible even after correction 6. Therefore, appropriate screening, prevention, and treatment are essential to avoid these long-term consequences.