What is the next step in managing a child with severe iron deficiency anemia, characterized by a low hemoglobin level and microcytosis (Mean Corpuscular Volume (MCV) is low)?

Oral Iron Supplementation with Dietary Modification (Option C)

The next step is oral iron supplementation at 3 mg/kg/day of elemental iron with dietary modifications—blood transfusion is not indicated in this hemodynamically stable child despite the severely low hemoglobin of 6.2 g/dL. 1

Rationale for Avoiding Transfusion

• CDC guidelines explicitly recommend oral iron supplementation as first-line treatment for presumptive iron deficiency anemia in stable children, regardless of severity, with hemoglobin levels as low as 6.2 g/dL 1
• Blood transfusion is reserved exclusively for children with hemodynamic instability (tachycardia, hypotension), which is not described in this case 1
• Premature transfusion in stable patients is unnecessary and carries risks including transfusion reactions, iron overload, and infectious complications 1

Why Not Bone Marrow Biopsy

• The combination of low hemoglobin and low MCV (microcytosis) in a young child is pathognomonic for iron deficiency anemia until proven otherwise 1
• Bone marrow biopsy would only be considered if the patient fails to respond to oral iron therapy after 4 weeks, suggesting alternative diagnoses 1, 2

Specific Treatment Protocol

Prescribe 3 mg/kg per day of elemental iron, administered between meals for optimal absorption 1

• For a 5-6 year old child (approximately 18-20 kg), this equals roughly 54-60 mg elemental iron daily 1
• Iron drops or liquid formulations are preferred over tablets in this age group 1
• Administer between meals to maximize absorption—giving iron with meals decreases absorption significantly 1

Critical Dietary Modifications

• Limit milk intake to 24 oz (720 mL) daily, as excessive milk consumption is a common cause of iron deficiency in young children 1
• Introduce iron-fortified cereals 1
• Add vitamin C-rich foods (citrus fruits, tomatoes, strawberries) to enhance iron absorption 1
• Include pureed or soft meats as age-appropriate sources of heme iron 1

Monitoring Algorithm

Repeat hemoglobin/hematocrit at 4 weeks to confirm treatment response 1

• An increase of ≥1 g/dL in hemoglobin or ≥3% in hematocrit indicates adequate response 1
• If responsive, continue iron therapy for 2-3 additional months after hemoglobin normalizes to replenish iron stores 1
• Reassess hemoglobin approximately 6 months after completing treatment 1

When to Escalate Workup

If the patient fails to respond to oral iron at 4 weeks:

• Evaluate for celiac disease, inflammatory bowel disease, or chronic infection 1
• Consider gastrointestinal blood loss from occult sources or parasitic infections 1
• Assess for malabsorption disorders requiring intravenous iron 2
• Test for thalassemia if RDW is normal or near normal (RDW >14.0% suggests iron deficiency, while RDW ≤14.0% suggests thalassemia minor) 2

Common Pitfalls to Avoid

• Inadequate treatment duration: Stopping iron therapy when hemoglobin normalizes without replenishing stores leads to rapid recurrence 1
• Poor compliance: Gastrointestinal side effects (constipation, nausea) can be managed by adjusting timing or switching to alternative formulations like ferrous gluconate 1, 2
• Failure to address dietary causes: Without correcting excessive milk intake and poor dietary iron sources, anemia will recur after treatment cessation 1
• Overlooking developmental consequences: Iron deficiency anemia in children aged 1-5 years causes developmental delays, decreased motor activity, impaired social interaction, and reduced attention span that may persist past school age if not fully reversed 1