What should I do if a 3-year-old child ingested an iron supplement and now has diarrhea?

Immediate Assessment and Management of Iron Ingestion in a 3-Year-Old

This child requires immediate evaluation at an emergency department if they ingested ≥40 mg/kg of elemental iron or are experiencing persistent/severe symptoms beyond mild diarrhea. 1

Critical Initial Triage Decision

Calculate the elemental iron dose ingested:

• Determine the exact number of tablets and the elemental iron content per tablet
• Calculate mg/kg based on the child's weight
• If ≥40 mg/kg of elemental iron was ingested, refer immediately to an emergency department 1
• If <40 mg/kg and only mild symptoms present, home observation may be appropriate 1

Symptom Assessment

Distinguish between mild and severe symptoms:

Mild symptoms (may observe at home if dose <40 mg/kg): 1

• Isolated vomiting or diarrhea that is not persistent
• These gastrointestinal symptoms occur frequently with iron ingestion and do not automatically require emergency evaluation 1

Severe symptoms requiring immediate emergency referral: 1

• Persistent vomiting or diarrhea
• Hematemesis (bloody vomit)
• Bloody diarrhea
• Altered level of consciousness
• Severe or protracted abdominal pain 2

Time Since Ingestion

If >6 hours have passed since ingestion and the child remains asymptomatic, they are unlikely to develop symptoms and do not require referral or prolonged observation 1

What NOT to Do at Home

Do not administer any of the following: 1

• Ipecac syrup
• Activated charcoal (iron is not adsorbed by charcoal)
• Cathartics
• Oral complexing agents (bicarbonate or phosphate solutions)

Hospital Management (If Referral Required)

If the child meets criteria for emergency evaluation, hospital management will include: 3, 1

• Serum iron concentration measurement
• Abdominal radiography to visualize retained tablets 3
• Gastric decontamination if indicated
• Whole-bowel irrigation with polyethylene glycol-electrolyte solution for significant ingestions 3
• Deferoxamine chelation therapy for severe toxicity (serum iron >500 μg/dL or severe symptoms) 4, 3

Key Pitfalls to Avoid

Common errors in management:

• Assuming all diarrhea requires emergency evaluation—mild, isolated diarrhea is common and expected 1
• Attempting home decontamination with activated charcoal or other agents (ineffective and potentially harmful) 1
• Failing to calculate actual elemental iron dose (different formulations contain different amounts of elemental iron)
• Delaying evaluation when severe symptoms are present, particularly persistent vomiting, bloody stools, or altered consciousness 1

Special Considerations

Type of iron product matters:

• Adult ferrous salt formulations (ferrous sulfate, ferrous gluconate, ferrous fumarate) pose the highest risk 1
• Children's chewable vitamins with iron typically require only home observation due to lower elemental iron content 1
• Enteric-coated preparations can cause distal bowel injury even with proximal sparing 2

Late complications to monitor for:

• Hepatic necrosis can develop 48-72 hours post-ingestion 5
• Gastrointestinal strictures may occur weeks later 4
• Coagulopathy and acute liver failure are associated with high mortality 5