What is the appropriate treatment for an 8-year-old male with iron deficiency anemia (IDA), presenting with fatigue and a low iron level of 35 micrograms per deciliter (mcg/dL)?

Treatment of Iron Deficiency Anemia in an 8-Year-Old Male

Start oral ferrous sulfate 3 mg/kg/day (approximately 65-100 mg elemental iron daily for most 8-year-olds) immediately, given once daily on an empty stomach, and continue for 3 months after hemoglobin normalizes to fully replenish iron stores. 1, 2

Immediate Treatment Protocol

Prescribe oral iron supplementation at 3 mg/kg per day of elemental iron, administered between meals for optimal absorption. 1 For an average 8-year-old weighing 25-30 kg, this translates to approximately 75-90 mg of elemental iron daily, which can be achieved with one ferrous sulfate 325 mg tablet (containing 65 mg elemental iron) once daily. 3

• Once-daily dosing is superior to multiple daily doses because it improves tolerance while maintaining equal or better iron absorption due to hepcidin regulation. 2
• The iron should be taken between meals (on an empty stomach) for maximum absorption, though taking with food is acceptable if gastrointestinal side effects occur. 1, 2
• Add vitamin C (ascorbic acid) 500 mg with each iron dose to enhance absorption, particularly critical given the severely low iron level of 35 mcg/dL. 2

Expected Response and Monitoring Timeline

Check hemoglobin in 4 weeks, expecting an increase of ≥1 g/dL (or hematocrit increase of ≥3%). 1 This confirms the diagnosis of iron deficiency anemia and indicates treatment response. 1

• If hemoglobin rises appropriately at 4 weeks, continue iron treatment for 2 more months (total 3 months), then recheck hemoglobin. 1
• After successful normalization of hemoglobin, continue iron supplementation for an additional 3 months to fully replenish iron stores. 2
• Reassess hemoglobin approximately 6 months after completing treatment. 1

If Treatment Fails After 4 Weeks

If anemia does not respond to iron treatment despite compliance and absence of acute illness, further laboratory evaluation is required:

• Measure MCV, RDW, and serum ferritin concentration. 1
• Serum ferritin <15 μg/L confirms iron deficiency, while ferritin >15 μg/L suggests iron deficiency is not the cause of anemia. 1
• Consider alternative diagnoses or malabsorption conditions requiring different management. 1, 2

Dietary Counseling

Counsel parents about adequate dietary iron intake to correct the underlying problem of low iron consumption. 1 This includes:

• Incorporating iron-rich foods (red meat, fortified cereals, beans, dark leafy greens) regularly into the diet. 4
• Identifying and including iron absorption enhancers (vitamin C-rich foods like citrus, tomatoes, peppers). 4
• Avoiding iron absorption inhibitors (excessive dairy, tea, coffee, high-fiber foods) around iron-rich meals. 4

When to Consider Intravenous Iron

Intravenous iron is not typically first-line in pediatric iron deficiency anemia but should be considered if: 2

• The child cannot tolerate oral iron despite trying at least two different oral preparations. 2
• There is inadequate response to oral iron therapy after 4 weeks of compliant treatment. 2
• Underlying malabsorption conditions are identified (celiac disease, inflammatory bowel disease). 2

Investigation of Underlying Cause

While treating with iron supplementation, assess for risk factors that led to iron deficiency: 1

• Dietary history: Excessive cow's milk intake (>24 oz daily), inadequate iron-fortified foods, vegetarian diet. 1
• Blood loss: Gastrointestinal bleeding, parasitic infections, frequent nosebleeds. 1
• Malabsorption: Celiac disease screening if poor response to treatment. 2
• Special health-care needs: Chronic medications, inflammatory disorders, recent surgery. 1

Critical Pitfalls to Avoid

• Do not prescribe multiple daily doses - this increases gastrointestinal side effects without improving efficacy due to hepcidin-mediated absorption blockade. 2
• Do not stop iron therapy when hemoglobin normalizes - continue for 3 months after correction to replenish stores. 1, 2
• Do not overlook vitamin C supplementation when oral iron response is suboptimal, as it significantly enhances absorption. 2
• Do not delay treatment while awaiting extensive diagnostic workup - begin iron supplementation immediately upon diagnosis. 2
• Do not fail to counsel about dietary iron intake - supplementation alone without addressing underlying dietary deficiency leads to recurrence. 1