What is the recommended treatment for pediatric patients with iron deficiency?

Treatment of Iron Deficiency in Pediatric Patients

For pediatric patients with iron deficiency anemia, oral ferrous sulfate at a dose of 3 mg/kg per day administered between meals is the recommended first-line treatment, along with dietary counseling to address underlying iron intake issues. 1

Diagnosis and Confirmation

• Diagnose iron deficiency anemia through hemoglobin (Hb) concentration or hematocrit (Hct) tests, with confirmation requiring a repeat test if initial screening is positive 1
• A presumptive diagnosis can be made when two tests agree and the child is not ill 1
• Confirmation of iron deficiency anemia is established when treatment results in an increase in Hb ≥1 g/dL or Hct ≥3% after 4 weeks of therapy 1, 2

Treatment Protocol

Oral Iron Therapy

• Dosage: Administer 3 mg/kg per day of elemental iron, typically as ferrous sulfate drops 1, 2
• Administration: Give between meals to maximize absorption 1
• Duration: Continue treatment for 2 additional months after normalization of hemoglobin to replenish iron stores 1, 2
• Monitoring: Repeat hemoglobin testing at 4 weeks to confirm diagnosis and response, at the end of treatment, and again 6 months later 1, 2

Special Populations

• Preterm or low birthweight infants: Higher dosage of 2-4 mg/kg per day of iron drops (maximum 15 mg/day) starting at 1 month of age and continuing until 12 months 1
• Breastfed infants with insufficient iron from supplementary foods: 1 mg/kg per day of iron drops by 6 months of age 1

Non-Responders

• If no response after 4 weeks despite compliance and absence of acute illness, further evaluate with additional laboratory tests including MCV, RDW, and serum ferritin 1
• Consider alternative diagnoses or contributing factors if response is inadequate 1

Prevention Strategies

Primary Prevention

• Breastfed infants: Exclusive breastfeeding for 4-6 months, then introduce iron-rich complementary foods 1
• Formula-fed infants: Use only iron-fortified infant formula until 12 months of age 1
• Dietary recommendations:
  • Introduce iron-fortified infant cereal at 4-6 months (two or more servings daily) 1
  • Include vitamin C-rich foods daily by 6 months to enhance 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 aged 1-5 years 1
  • Avoid cow's milk before 12 months of age 1

Screening Recommendations

• Universal screening for high-risk populations (low-income, WIC-eligible, migrant, refugee children) 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 not receiving iron-fortified formula 1
  • Infants fed non-iron-fortified formula for >2 months 1
  • Infants introduced to cow's milk before 12 months 1
  • Breastfed infants with inadequate iron from supplementary foods after 6 months 1
  • Children consuming >24 oz of cow's milk daily 1
  • Children with special healthcare needs affecting iron status 1

Alternative Formulations and Special Considerations

• Ferrous sulfate solution (2 mg/kg/day) has shown high efficacy with normalization of hemoglobin in 95% of young children after 3 months 3
• Bis-glycinate iron formulations may offer a good efficacy/safety profile with fewer gastrointestinal side effects compared to ferrous salts 4
• For patients receiving parenteral nutrition, iron supplementation should preferentially be given enterally if tolerated 1
• Parenteral iron (iron sucrose) may be considered for children who cannot maintain adequate iron status using enteral supplements, particularly those on long-term parenteral nutrition 1

Common Pitfalls and Caveats

• Untreated iron deficiency anemia in early childhood, especially if severe and prolonged, can result in neurodevelopmental and cognitive deficits that may not be fully reversible 5
• Gastrointestinal side effects are common with ferrous iron preparations (14-16%) but less frequent with newer formulations like bis-glycinate (6%) 4
• Excessive iron supplementation can lead to iron overload; regular monitoring of iron status is essential for patients on long-term therapy 1
• Failure to address the underlying cause of iron deficiency may result in recurrence after treatment 1