What is the recommended iron supplementation for a 2-year-old child with iron deficiency anemia?

Iron Supplementation for a 2-Year-Old with Iron Deficiency Anemia

For a 2-year-old child with confirmed iron deficiency anemia, prescribe 3 mg/kg per day of elemental iron as ferrous sulfate drops, administered between meals, and continue treatment for approximately 3 months total (2 months after hemoglobin normalizes). 1, 2

Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis:

• Obtain a repeat hemoglobin or hematocrit if the initial screening was positive 1
• If both tests agree and the child is not acutely ill, you can make a presumptive diagnosis and begin treatment 1
• Serum ferritin ≤15 μg/L confirms iron deficiency if you need additional confirmation 1, 3

Treatment Protocol

Iron Dosing and Administration

• Prescribe 3 mg/kg per day of elemental iron (as ferrous sulfate drops) 1, 2, 3
• Administer between meals to optimize absorption, though this may increase gastrointestinal side effects 2
• Ferrous sulfate is superior to iron polysaccharide complex, producing a 1.0 g/dL greater increase in hemoglobin at 12 weeks and higher rates of complete resolution 4

Treatment Duration

• Continue iron for 2 months after hemoglobin normalizes, for a total treatment duration of approximately 3 months 2, 3, 5
• This extended duration is critical to replenish iron stores, not just correct the anemia 3

Monitoring Response

4-Week Follow-Up

• Recheck hemoglobin or hematocrit at 4 weeks 1, 2
• An increase of ≥1 g/dL in hemoglobin or ≥3% in hematocrit confirms the diagnosis of iron deficiency anemia 1, 2, 3
• If confirmed, reinforce dietary counseling and continue iron for 2 additional months 1

End of Treatment and Beyond

• Recheck hemoglobin at the end of the 3-month treatment course 1
• Reassess approximately 6 months after successful treatment completion to ensure no recurrence 1, 6

Dietary Counseling (Essential Component)

Address the underlying cause of iron deficiency:

• Limit cow's milk, goat's milk, or soy milk to no more than 24 oz (720 mL) daily 1, 2, 6
• Include vitamin C-rich foods (fruits, vegetables, juices) with meals to enhance iron absorption 2
• Encourage iron-rich foods including iron-fortified cereals and meat 2

Management of Non-Response

If anemia does not improve after 4 weeks despite documented compliance and absence of acute illness:

• Obtain additional laboratory tests: MCV, RDW, and serum ferritin 1
• Consider other causes: copper deficiency, ceruloplasmin deficiency, vitamin B12 deficiency 3, 6
• Serum ferritin >15 μg/L suggests iron deficiency is not the cause of the anemia 1
• Consider pediatric hematology referral for refractory cases 7

Common Pitfalls to Avoid

• Inadequate treatment duration: Stopping iron when hemoglobin normalizes without the additional 2 months fails to replenish stores and leads to recurrence 3, 6
• Excessive milk intake: Children consuming >24 oz daily of cow's milk are at high risk for iron deficiency 1
• Poor compliance: Gastrointestinal side effects are common but can be managed by adjusting timing or considering alternative formulations, though ferrous sulfate remains most effective 4
• Failure to address diet: Without dietary modification, iron deficiency will recur after treatment ends 1, 6

Important Context

While the CDC guidelines are from 1998 1, they remain the authoritative source for pediatric iron deficiency management and are consistently referenced in current clinical practice 2, 3, 6. More recent evidence from 2017 confirms that low-dose (3 mg/kg/day) ferrous sulfate is highly effective and should be the preferred formulation 4.