What is the recommended treatment for iron deficiency without anemia in pediatric patients?

Treatment of Iron Deficiency Without Anemia in Pediatrics

For pediatric patients with iron deficiency without anemia, oral iron supplementation is the recommended first-line treatment, with dosing of 3 mg/kg/day of elemental iron administered between meals for infants and young children, or 28-50 mg of elemental iron daily for older children and adolescents. 1, 2

Diagnostic Thresholds for Iron Deficiency Without Anemia

Before initiating treatment, confirm iron deficiency using the following ferritin cut-offs in the absence of inflammation (normal C-reactive protein):

• Children 6-12 years: Ferritin <15 µg/L 2
• Adolescents 12-15 years: Ferritin <20 µg/L 2
• Adolescents >15 years and adults: Ferritin <30 µg/L 2

For patients with chronic kidney disease specifically, different thresholds apply: TSAT ≤20% and ferritin ≤100 ng/mL warrant treatment 1, 3

Oral Iron Therapy Protocol

Dosing Recommendations

Infants and young children:

• Standard dose: 3 mg/kg/day of elemental iron, administered between meals 1
• For breast-fed infants >6 months with insufficient dietary iron: 1 mg/kg/day of iron drops 1
• For preterm or low-birthweight breast-fed infants: 2-4 mg/kg/day (maximum 15 mg/day) starting at 1 month of age 1

Older children and adolescents:

• Use preparations containing 28-50 mg of elemental iron to minimize gastrointestinal side effects while maintaining efficacy 2
• Adolescent girls: 60 mg/day 1

Optimizing Absorption

• Administer iron between meals on an empty stomach for maximum absorption 1
• Encourage consumption of vitamin C-rich foods with iron to enhance absorption 1
• Avoid concurrent intake of calcium, tea, coffee, or antacids which inhibit iron absorption 2

Monitoring and Follow-Up

Reassess iron status after 8-10 weeks of oral therapy by repeating hemoglobin and ferritin levels 2. Success is defined by normalization of ferritin levels and resolution of symptoms. For patients with recurrent iron deficiency, consider intermittent oral supplementation and monitor every 6-12 months 2.

Indications for Intravenous Iron Therapy

While oral iron is first-line for uncomplicated iron deficiency without anemia, IV iron should be considered in specific circumstances:

Primary Indications for IV Iron

• Malabsorption disorders: Inflammatory bowel disease, celiac disease, or intestinal failure where oral absorption is impaired 3, 4
• Chronic kidney disease: Particularly hemodialysis patients 1, 3
• Failed oral therapy: Lack of response after 8-10 weeks of compliant oral supplementation 4, 5, 2
• Intolerable side effects: Severe gastrointestinal symptoms preventing adherence to oral therapy 5, 6
• Urgent need for rapid repletion: Though this is less common in iron deficiency without anemia 4

IV Iron Formulations and Safety

Iron sucrose is the most studied and recommended IV iron preparation for children, with lower risk of adverse reactions compared to iron dextran 1, 3. Iron sucrose is FDA-approved for children ≥2 years with chronic kidney disease 1. Ferric carboxymaltose (FCM) offers the advantage of fewer infusions and shorter treatment duration 6.

Critical safety requirement: IV iron administration must be performed by personnel trained in emergency treatment with immediate access to resuscitation equipment and medications for allergic reactions 1, 3. For iron dextran specifically, a test dose is mandatory before the first therapeutic dose 1, 3.

Important Caveats

• Do not supplement iron in patients with normal or high ferritin levels (>30 µg/L in adolescents >15 years), as this is ineffective and potentially harmful 2
• Exclude inflammation before interpreting ferritin: Check C-reactive protein, as ferritin is an acute phase reactant and may be falsely elevated despite true iron deficiency 2
• Avoid excessive cow's milk intake: Limit to <24 oz/day in children 1-5 years, as excessive milk consumption is a major risk factor for iron deficiency 1
• For patients on parenteral nutrition: Preferentially give iron enterally if tolerated rather than adding to PN solutions 1, 3

The evidence strongly supports oral iron as first-line therapy for uncomplicated iron deficiency without anemia in pediatrics, reserving IV iron for specific clinical scenarios where oral therapy has failed or is contraindicated 1, 2. Recent studies demonstrate that when IV iron is needed, modern formulations like iron sucrose and FCM offer excellent safety profiles with significantly better adherence than oral therapy 5, 6.