What is the first line treatment for iron deficiency in pediatric patients?

First-Line Treatment for Pediatric Iron Deficiency

Oral ferrous sulfate at 3 mg/kg per day of elemental iron, administered between meals in 2-3 divided doses, is the first-line treatment for iron deficiency in pediatric patients. 1, 2

Treatment Protocol

Standard Dosing

• Administer 3 mg/kg/day of elemental iron in divided doses between meals for optimal absorption in most pediatric patients 1, 2
• Each 324 mg tablet of ferrous sulfate contains 65 mg of elemental iron 3
• Ferrous sulfate is preferred over other iron salts (ferrous gluconate, ferrous fumarate) because it is the most cost-effective and provides known amounts of elemental iron 4

Age-Specific Dosing Adjustments

• Preterm or low birthweight infants: 2-4 mg/kg/day of iron drops (maximum 15 mg/day) starting at 1 month of age until 12 months 1, 2
• Breastfed infants (6-12 months): 1 mg/kg/day of iron drops if insufficient iron from supplementary foods 1, 2
• School-age children (5-12 years): One 60-mg iron tablet daily 2
• Adolescent boys (12-18 years): Two 60-mg iron tablets daily 2

Administration Guidelines

Timing and Absorption

• Give iron between meals (without food) to maximize absorption, as food can reduce iron absorption by up to 50% 4
• Avoid administering within 2 hours before or 1 hour after meals 4
• Aluminum-based phosphate binders can reduce iron absorption and should be avoided 4

Treatment Duration and Monitoring

• Continue treatment for 2-3 months after hemoglobin normalization to replenish iron stores 2
• Recheck hemoglobin/hematocrit at 4 weeks: An increase in hemoglobin ≥1 g/dL or hematocrit ≥3% confirms adequate response and diagnosis 1, 2
• Recheck hemoglobin at the end of treatment and again 6 months later 5

Dietary Counseling (Essential Component)

Always combine iron supplementation with dietary counseling to address underlying low iron intake 1, 2

Key Dietary Recommendations

• Limit milk consumption to ≤24 oz daily in children 1-5 years, as excessive milk intake displaces iron-rich foods and can cause occult blood loss 2
• Introduce iron-fortified infant cereal at 4-6 months (two or more servings daily) 1, 2
• Include vitamin C-rich foods with meals to enhance iron absorption 1, 2
• Use only iron-fortified infant formula (not cow's milk, goat's milk, or soy milk) until 12 months of age 1, 2

Alternative Formulations (Second-Line)

When to Consider Parenteral Iron

• Reserve IV iron for patients who cannot tolerate oral supplementation or have failed oral therapy 1, 6
• Iron sucrose is the recommended parenteral formulation for children, particularly those on long-term parenteral nutrition 1
• A 2024 study demonstrated that IV iron has significantly better adherence (70.1% vs 43.0%) and fewer adverse effects (3.7% vs 77.9%) compared to oral iron in patients who failed oral therapy 6

Test Dose Considerations

• For iron dextran or iron gluconate, administer a test dose (25 mg) with personnel trained in emergency treatment immediately available 4
• Important caveat: Test doses have limited predictive value, as most severe reactions occur in patients who previously tolerated test doses 4
• Maintain caution with every dose administered 4

Common Pitfalls to Avoid

• Do not use iron polysaccharide complex: Despite being more expensive, it is no better tolerated and may be less effective than ferrous sulfate 4
• Do not add ascorbic acid: It does not improve ferrous iron absorption 4
• Do not ignore adherence issues: If patients have difficulty tolerating oral iron, start with smaller, more frequent doses and gradually increase to target dose 4
• Do not forget to address underlying causes: Failure to identify and correct the source of iron deficiency (e.g., excessive milk intake, blood loss) will lead to recurrence 2

Monitoring for Iron Overload

• Regular monitoring of iron status is essential for patients on long-term therapy to prevent iron overload 1
• This is particularly important for children receiving parenteral iron supplementation 1