What is the treatment for low hemoglobin (iron deficiency anemia) in children?

Treatment of Iron Deficiency Anemia in Children

The standard treatment for iron deficiency anemia in children is oral iron supplementation at a dose of 3 mg/kg per day of elemental iron administered between meals, along with dietary counseling to address underlying low iron intake. 1

Diagnosis Confirmation

• Before initiating treatment, confirm iron deficiency anemia with repeat hemoglobin/hematocrit testing 1
• A presumptive diagnosis can be made in a non-ill child with positive anemia screening and confirmed with laboratory tests 1
• Low serum ferritin (≤15 μg/L) confirms iron deficiency anemia 1

Treatment Protocol

Oral Iron Supplementation

• Ferrous sulfate is the preferred form of oral iron supplementation as it has been shown to be more effective than iron polysaccharide complex in increasing hemoglobin concentration 2
• Administer 3 mg/kg per day of elemental iron between meals to maximize absorption 1
• Continue treatment for at least 2-3 months after hemoglobin normalization to replenish iron stores 1
• Monitor treatment response by repeating hemoglobin/hematocrit in 4 weeks; an increase in hemoglobin ≥1 g/dL or hematocrit ≥3% confirms diagnosis and adequate response 3

Age-Specific Dosing

• For infants under 12 months:
  • Breastfed infants with insufficient iron from foods: 1 mg/kg/day iron drops 1
  • Preterm or low birthweight breastfed infants: 2-4 mg/kg/day iron drops (maximum 15 mg/day) from 1 month until 12 months 1
• For school-age children (5-12 years): one 60-mg iron tablet daily plus dietary counseling 1
• For adolescent boys (12-18 years): two 60-mg iron tablets daily plus dietary counseling 1

Dietary Recommendations

• For infants:
  • Use only iron-fortified infant formula if not breastfeeding 3
  • Avoid cow's milk, goat's milk, and soy milk until age 12 months 3
  • Introduce iron-fortified infant cereal at 4-6 months (two or more servings daily) 3
  • Include vitamin C-rich foods with meals to improve iron absorption 3
• For children 1-5 years:
  • Limit milk consumption to no more than 24 oz daily 3
  • Encourage iron-rich foods (meats, beans, fortified cereals) 1
  • Pair iron-rich foods with vitamin C sources to enhance absorption 1

Management of Refractory Cases

• If no response after 4 weeks of treatment despite compliance:
  • Further evaluate with additional laboratory tests including MCV, RDW, and serum ferritin 3
  • Consider intravenous iron therapy for cases refractory to oral treatment 4
  • Iron sucrose is the most commonly used intravenous preparation (48% of pediatric hematologists prefer this option) 4

Duration of Treatment

• Continue iron therapy for 2 additional months after hemoglobin normalization 3
• Reassess hemoglobin concentration approximately 6 months after successful treatment completion 3
• Total treatment duration typically ranges from 3-6 months depending on severity and response 5

Common Pitfalls and Caveats

• Excessive milk intake can contribute to iron deficiency by displacing iron-rich foods and potentially causing occult blood loss 1
• Failure to address underlying causes of iron deficiency may lead to recurrence after treatment 1
• Gastrointestinal side effects (particularly diarrhea) are common with iron supplementation, but ferrous sulfate may be better tolerated than iron polysaccharide complex 2
• Neurodevelopmental and cognitive deficits from severe and prolonged iron deficiency anemia may not be fully reversible even after correction of anemia, emphasizing the importance of prompt treatment 5
• Dosing frequency: Both daily (3-7 times/week) and intermittent (1-2 times/week) iron regimens are effective at decreasing anemia, though daily supplementation leads to greater increases in ferritin levels 6