Treatment of Low Hemoglobin in Children
For children with presumptive iron-deficiency anemia, initiate oral ferrous sulfate at 3 mg/kg per day of elemental iron, administered between meals, and reassess hemoglobin after 4 weeks to confirm diagnosis and guide continued therapy. 1
Diagnostic Confirmation
Before initiating treatment, confirm anemia using age-specific hemoglobin thresholds 1, 2:
- Children 0.5-5 years: Hb <11.0 g/dL
- Children 5-12 years: Hb <11.5 g/dL
- Children 12-15 years: Hb <12.0 g/dL
- Males ≥15 years: Hb <13.0 g/dL
- Females ≥15 years: Hb <12.0 g/dL
If initial screening is positive, repeat the hemoglobin test to confirm before starting treatment 1. If both tests agree and the child is not acutely ill, presume iron-deficiency anemia and begin therapy 1.
Treatment Protocol
Initial Therapy
Administer ferrous sulfate 3 mg/kg per day of elemental iron between meals to maximize absorption 1. Recent high-quality evidence confirms that low-dose ferrous sulfate (3 mg/kg/day) is superior to iron polysaccharide complex, producing a 1.0 g/dL greater increase in hemoglobin at 12 weeks 3. This once-daily dosing achieves complete resolution of iron-deficiency anemia in 29% of children by 12 weeks 3.
Dietary Counseling
Simultaneously counsel parents on correcting underlying dietary iron deficiency 1:
- Limit cow's milk to <24 oz daily (excess milk consumption is a major risk factor) 1, 2
- Introduce iron-rich foods and iron-fortified cereals 1
- Encourage vitamin C-rich foods with meals to enhance iron absorption 1
- For breastfed infants >6 months, ensure adequate iron from supplementary foods 1, 2
Response Assessment and Duration
Recheck hemoglobin at 4 weeks 1. An increase of ≥1 g/dL (or hematocrit increase ≥3%) confirms iron-deficiency anemia as the diagnosis 1.
If Response is Adequate:
- Continue iron therapy for 2 additional months (total 3 months) to replenish iron stores 1, 4
- Recheck hemoglobin at completion of treatment 1
- Reassess hemoglobin approximately 6 months after successful treatment 1
Recent meta-analysis data suggests that treatment durations <3 months show the highest effect size (2.39 g/dL improvement), while 3-6 month durations show lower effect sizes (1.58 g/dL) 5. However, the established guideline recommendation of 3 months total treatment remains appropriate to ensure adequate iron store repletion 1.
If No Response After 4 Weeks:
Despite compliance and absence of acute illness, further evaluate with 1:
- Mean corpuscular volume (MCV)
- Red cell distribution width (RDW)
- Serum ferritin (≤15 μg/L confirms iron deficiency; >15 μg/L suggests alternative diagnosis) 1
- Consider hemoglobin electrophoresis if hemoglobinopathy suspected 2
Age-Specific Dosing Adjustments
School-age children (5-12 years): One 60-mg elemental iron tablet daily 1
Adolescent boys (12-18 years): Two 60-mg elemental iron tablets daily 1
Adolescent girls and women: Follow same screening and treatment protocols as adolescent boys, with particular attention to menstrual blood loss 1
Common Pitfalls and Caveats
Administration timing matters: Iron should be given between meals for optimal absorption, though this may increase gastrointestinal side effects 1. If tolerability is poor, administration with food is acceptable despite reduced absorption 3.
Avoid premature discontinuation: The most common error is stopping treatment once hemoglobin normalizes without completing the full 3-month course needed to replenish iron stores 1.
Diarrhea may occur: While ferrous sulfate is better tolerated than iron polysaccharide complex overall, some children experience gastrointestinal symptoms 3. Diarrhea was actually more common with iron polysaccharide complex (58% vs 35%) 3.
Screen high-risk populations proactively: Children from low-income families, WIC-eligible children, preterm/low-birthweight infants, and those consuming >24 oz daily of cow's milk require screening at 9-12 months, again at 15-18 months, and annually from ages 2-5 years 1.
Developmental consequences are reversible if treated early: Iron-deficiency anemia causes developmental delays, decreased motor activity, and impaired social interaction in young children, but these effects may persist past school age if not fully corrected 1. Additionally, iron deficiency increases lead absorption, compounding neurodevelopmental risk 1.