Does a patient with low Red Blood Cell (RBC) count, low Hemoglobin (HGB), low Hematocrit (HCT), high Red Cell Distribution Width (RDW), and low Ferritin levels require iron supplementation?

Iron Supplementation is Indicated

Yes, this 16-year-old requires iron supplementation based on her laboratory findings showing iron deficiency anemia with low ferritin (19 ng/mL), low hemoglobin (10.6 g/dL), low hematocrit (32.2%), and elevated RDW (18.3%). 1

Diagnostic Interpretation

The laboratory profile clearly demonstrates iron deficiency anemia:

• Ferritin of 19 ng/mL is significantly below the threshold of 35 μg/L used to define iron deficiency, even though TIBC is normal 1
• The elevated RDW (18.3%) is characteristic of iron deficiency, as RDW increases concomitantly with the development of iron deficiency before microcytosis becomes evident 2
• Hemoglobin of 10.6 g/dL is below the anemia threshold for females (normal >11.5 g/dL) 1
• The combination of low ferritin with anemia confirms iron deficiency anemia rather than isolated iron depletion 3

Treatment Recommendation

Initiate oral iron supplementation immediately with ferrous sulfate 200 mg three times daily (or ferrous gluconate/ferrous fumarate as equally effective alternatives) 1

Specific Treatment Protocol:

• Start with ferrous sulfate 200 mg orally three times daily, which is the most cost-effective first-line therapy 1
• Continue supplementation for 3 months after hemoglobin normalizes to adequately replenish iron stores 1
• Co-administer with vitamin C (ascorbic acid) to enhance iron absorption, particularly if response is suboptimal 1
• Expected response: hemoglobin should increase by 2 g/dL after 3-4 weeks of treatment 1

Age-Specific Considerations

For a 16-year-old female, menstrual blood loss is the most likely etiology, as iron deficiency occurs in 5-10% of menstruating women 1

• Menstrual losses, especially menorrhagia, are the primary cause of iron deficiency in this age group 1
• Dietary assessment is essential to identify inadequate iron intake, particularly if the patient follows a vegetarian or vegan diet where iron bioavailability is substantially lower 1
• No extensive gastrointestinal investigation is warranted in a menstruating adolescent with typical iron deficiency anemia unless there are concerning symptoms or failure to respond to therapy 1

Monitoring Strategy

Follow-up hemoglobin and MCV should be checked after 3-4 weeks of treatment 1

• If hemoglobin fails to increase by at least 1 g/dL after 4 weeks, consider poor compliance, continued blood loss, malabsorption, or misdiagnosis 1
• Once hemoglobin normalizes, continue iron for 3 additional months to replenish stores 1
• After completing therapy, monitor hemoglobin and MCV at 3-month intervals for one year, then annually 1
• Recheck ferritin if anemia recurs to confirm iron store depletion 1

Common Pitfalls to Avoid

Do not delay treatment waiting for additional testing - the diagnosis is clear and treatment should begin immediately 1

• Normal TIBC does not exclude iron deficiency - ferritin is the definitive marker of iron stores 1
• Gastrointestinal side effects (constipation, nausea) occur commonly with oral iron; if intolerable with one preparation, switch to an alternative formulation or consider liquid preparations 1
• Parenteral iron is reserved only for intolerance to at least two oral preparations or documented malabsorption - it is more expensive, painful, and carries anaphylaxis risk without faster hemoglobin response 1
• Failure to continue therapy for 3 months after correction will result in inadequate store repletion and early recurrence 1

When to Investigate Further

Additional evaluation is only necessary if:

• Hemoglobin fails to respond appropriately after 4 weeks of compliant therapy 1
• Anemia cannot be maintained after initial correction despite ongoing supplementation 1
• Concerning symptoms suggest pathology beyond menstrual losses (e.g., gastrointestinal symptoms, weight loss) 1