What is the treatment for low ferritin (iron deficiency) levels in pediatric patients?

Treatment of Low Ferritin (Iron Deficiency) in Pediatric Patients

Oral iron supplementation is the first-line treatment for iron deficiency in pediatric patients, with a recommended dosage of 3-6 mg/kg/day of elemental iron, while intravenous iron therapy should be reserved for cases with poor response to oral therapy, compliance issues, or severe anemia. 1

Diagnostic Criteria for Iron Deficiency

• Iron deficiency should be diagnosed based on serum ferritin levels, with the following cut-offs 2:

  • Children 6-12 years: <15 μg/L
  • Adolescents 12-15 years: <20 μg/L
  • Adolescents >15 years: <30 μg/L

• Additional laboratory tests should include hemoglobin, hematocrit, mean cellular volume, mean cellular hemoglobin, and percentage of hypochromic erythrocytes to fully assess iron status 2

• C-reactive protein should be measured to exclude acute phase reactions that may falsely elevate ferritin levels despite iron deficiency 2

Oral Iron Therapy

• Oral iron is the preferred initial treatment for most pediatric patients with iron deficiency 1

• Recommended dosage: 3-6 mg/kg/day of elemental iron, divided into 1-3 doses 1

• Ferrous preparations are more cost-effective and better absorbed than ferric preparations 1

• To improve absorption and minimize gastrointestinal side effects 3:

  • Administer between meals or on an empty stomach
  • May be taken with meals if gastrointestinal discomfort occurs
  • Avoid administration within 2 hours of antibiotics

• Duration of therapy should be 8-10 weeks to replenish iron stores, with follow-up testing to confirm response 2

• Common side effects include gastrointestinal discomfort, constipation, and diarrhea 3

Indications for Intravenous Iron Therapy

Intravenous iron should be considered in the following situations 4, 5:

• Failure to respond to oral iron therapy
• Poor compliance with oral iron supplementation
• Intolerance to oral iron due to side effects
• Severe anemia requiring rapid correction
• Conditions with impaired iron absorption (inflammatory bowel disease, celiac disease)
• Chronic kidney disease

Intravenous Iron Administration

• Iron sucrose is the most studied and recommended IV iron preparation for children 6

  • Approved in the USA for children ≥2 years of age
  • Lower risk of adverse reactions compared to iron dextran

• For iron dextran administration 6:

  • A test dose should be given before the first therapeutic dose
  • For children <10 kg: 10 mg test dose
  • For children 10-20 kg: 15 mg test dose
  • For children >20 kg: 25 mg test dose

• Dosing recommendations for pediatric patients 6:

  • Children <10 kg: 25 mg per dose (for a 10-dose course)
  • Children 10-20 kg: 50 mg per dose (for a 10-dose course)
  • Children >20 kg: 100 mg per dose (for a 10-dose course)

• Ferric carboxymaltose has shown efficacy in pediatric patients with fewer infusions required compared to iron sucrose 5

Monitoring Response to Therapy

• Repeat hemoglobin, ferritin, and other iron parameters 8-10 weeks after initiating therapy 2

• For patients on long-term parenteral nutrition requiring iron supplementation, monitor iron status (at least ferritin and hemoglobin) regularly to prevent both iron deficiency and iron overload 6

• Patients with repeatedly low ferritin will benefit from intermittent oral supplementation and long-term follow-up every 6-12 months 2

Special Considerations

• For patients receiving parenteral nutrition 6:

  • Iron supplementation should preferentially be given enterally rather than parenterally if tolerated
  • Routine iron provision in parenteral nutrition is not recommended for short-term PN (<3 weeks)
  • For long-term PN, parenteral iron should be given if enteral supplementation is insufficient
  • Dosage: 200-250 μg/kg/day for preterm infants; 50-100 μg/kg/day (maximum 5 mg/day) for infants and children

• For children with chronic kidney disease 6:

  • Oral iron (or IV iron in hemodialysis patients) is recommended when TSAT ≤20% and ferritin ≤100 ng/ml
  • For those on erythropoietin-stimulating agents, maintain TSAT >20% and ferritin >100 ng/ml

Safety Considerations

• Accidental overdose of iron-containing products is a leading cause of fatal poisoning in children under 6 years 3

• Keep iron supplements out of reach of children 3

• Intravenous iron administration should be performed by personnel trained to provide emergency treatment with immediate access to medications needed for treating allergic reactions 6

• IV iron therapy has shown significantly fewer adverse effects (3.7%) compared to oral iron (77.9%) in pediatric patients who failed oral therapy 4