What is the guideline for treating iron deficiency anemia in adolescents?

Treatment of Iron Deficiency Anemia in Adolescents

Adolescent boys (ages 12-18) should receive 120 mg of elemental iron daily (two 60-mg tablets), while adolescent girls should receive 60-120 mg of elemental iron daily, combined with dietary counseling to optimize iron intake. 1

Initial Treatment Protocol

Dosing by Sex

• Adolescent boys (12-18 years): Prescribe two 60-mg iron tablets daily (120 mg total elemental iron) 1
• Adolescent girls (12-18 years): Prescribe 60-120 mg of elemental iron daily 1, 2
• Administer iron on an empty stomach or between meals to maximize absorption 2
• If gastrointestinal side effects occur, take with meals despite reduced absorption 2

Optimizing Absorption

• Recommend vitamin C-rich foods or supplements with iron to enhance absorption 2
• Avoid taking iron with calcium, tea, coffee, or dairy products which inhibit absorption 3
• Consider once-daily dosing in the morning rather than divided doses, as recent evidence suggests this maximizes absorption 3

Dietary Counseling

• Emphasize heme iron sources (meat, poultry, fish) which have superior bioavailability compared to plant-based non-heme iron 2
• For vegetarians/vegans, recommend increased total iron intake due to lower bioavailability of non-heme iron 3
• Pair plant-based iron sources with vitamin C-rich foods 2

Monitoring and Follow-Up

4-Week Assessment

• Recheck hemoglobin after 4 weeks of treatment 1, 2
• Expected response: Hemoglobin should increase by ≥1 g/dL 4
• If hemoglobin rises appropriately, continue iron supplementation for an additional 2-3 months to replenish iron stores 1, 2

Non-Response Protocol

If anemia does not respond after 4 weeks despite compliance and absence of acute illness, obtain additional laboratory tests 1:

• Mean corpuscular volume (MCV)
• Red blood cell distribution width (RDW)
• Serum ferritin (≤15 μg/L confirms iron deficiency; >15 μg/L suggests alternative diagnosis) 1

Important caveat: In adolescents of African, Mediterranean, or Southeast Asian ancestry, mild anemia unresponsive to iron therapy may indicate thalassemia minor or sickle cell trait 1

Post-Treatment Follow-Up

• Reassess hemoglobin approximately 6 months after completing successful treatment 1, 2
• For adolescent girls with risk factors (heavy menstrual bleeding, low dietary iron intake, restrictive diets, chronic conditions, high-level athletics), screen annually 2

Alternative Formulations and Routes

Oral Iron Alternatives

If ferrous sulfate is not tolerated 2:

• Try ferrous gluconate or ferrous fumarate
• Consider liquid preparations if tablets are poorly tolerated
• Ensure patient has tried at least two different oral preparations before considering parenteral therapy

Intravenous Iron Indications

Consider IV iron only when 2, 3:

• Intolerance to at least two oral iron preparations
• Documented non-compliance with oral therapy
• Severe and/or symptomatic anemia requiring rapid correction
• Chronic inflammatory conditions (e.g., inflammatory bowel disease) with compromised gastrointestinal absorption
• Persistent iron deficiency despite adequate trial of oral iron

Critical pitfall: Parenteral iron should not be first-line therapy as it is painful, expensive, and carries risk of anaphylactic reactions 2. The rise in hemoglobin with parenteral iron is typically no quicker than with oral preparations in most cases 2

Treatment Duration

• Minimum duration: Continue iron supplementation for 2-3 months after hemoglobin normalizes to replenish iron stores 1, 2
• Target ferritin: Aim for serum ferritin ≥20 ng/mL before discontinuing therapy 3
• Total treatment course: Typically 3 months minimum for confirmed iron deficiency anemia 4, 3

Common Pitfalls to Avoid

• Do not screen adolescent boys routinely unless they have history of iron deficiency anemia, special healthcare needs, or documented low iron intake 1
• Do not assume all microcytic anemia is iron deficiency—always consider thalassemia trait in at-risk populations 1
• Do not discontinue iron therapy as soon as hemoglobin normalizes—stores must be replenished 1
• Do not prescribe divided dosing throughout the day—once-daily dosing may be more effective 3