What is the treatment for a child under 6 with suspected iron toxicity and potential pre-existing gastrointestinal disorders or genetic conditions affecting iron metabolism?

Treatment of Iron Toxicity in Children Under 6

For a child under 6 with suspected iron toxicity, immediately initiate supportive care with gastrointestinal decontamination and administer intravenous deferoxamine chelation therapy if the child shows signs of systemic toxicity (shock, metabolic acidosis, altered mental status) or has ingested >60 mg/kg of elemental iron with serum iron levels exceeding the total iron-binding capacity. 1, 2

Initial Assessment and Risk Stratification

Determine the severity of ingestion:

• Calculate elemental iron dose ingested (mg/kg body weight) 2
• Ingestions >60 mg/kg are potentially serious and warrant aggressive intervention 2
• Obtain serum iron level at 4-6 hours post-ingestion, which is the most useful laboratory test to determine toxicity 3
• Serum iron >500 mcg/dL or exceeding total iron-binding capacity indicates severe toxicity requiring chelation 2

Assess for clinical signs of toxicity:

• Gastrointestinal symptoms: vomiting, diarrhea, abdominal pain, gastrointestinal hemorrhage 4, 2
• Cardiovascular collapse: shock, hypotension, tachycardia 4
• Metabolic derangements: severe anion gap metabolic acidosis 5
• Neurologic symptoms: altered mental status, lethargy, coma 5, 2
• Laboratory markers: hyperglycemia, leukocytosis, elevated aminotransferases 2, 6

Gastrointestinal Decontamination

Perform gastric lavage with deferoxamine-containing solution:

• Use solution containing deferoxamine and sodium bicarbonate for lavage 2
• Obtain abdominal radiograph to identify iron tablets in the gastrointestinal tract 2
• Consider whole-bowel irrigation with polyethylene glycol-electrolyte solution if tablets are visible on imaging and the child is stable 2

Important caveat: Do NOT induce emesis if the child is already symptomatic or has altered mental status, as this increases aspiration risk 1

Chelation Therapy with Deferoxamine

Indications for deferoxamine administration:

• Serum iron >500 mcg/dL or exceeding total iron-binding capacity 2
• Signs of systemic toxicity (shock, metabolic acidosis, altered mental status) regardless of serum iron level 5, 4
• Ingestion >60 mg/kg with symptomatic presentation 2

Deferoxamine dosing protocol:

• Administer by continuous intravenous infusion at 15 mg/kg/hour 1, 2
• Continue infusion until serum iron normalizes and clinical symptoms resolve, typically 24-48 hours 5, 2
• Monitor for characteristic "vin rosé" (rose-colored) urine indicating iron-deferoxamine complex excretion 4

Critical monitoring during chelation:

• Serial serum iron levels every 4-6 hours until declining and <350 mcg/dL 5, 2
• Continuous cardiovascular monitoring for hypotension 1
• Assess for resolution of metabolic acidosis 5

Supportive Care Measures

Address cardiovascular instability:

• Maintain intravascular volume with intravenous fluids, blood products, and vasopressors as needed 1, 4
• Administer packed red blood cells if gastrointestinal hemorrhage causes significant blood loss 2

Correct metabolic derangements:

• Treat severe metabolic acidosis with sodium bicarbonate 4
• Monitor and correct coagulation disorders 4

Maintain airway and oxygenation:

• Ensure clear airway with suction if needed 1
• Provide supplemental oxygen for shock states 1

Special Considerations for Pre-existing Conditions

In children with genetic iron metabolism disorders:

• Patients with SLC11A2 defects, STEAP3 defects, or hypotransferrinemia are at higher risk for toxic iron loading even with therapeutic iron supplementation 7
• Monitor iron status closely with serial ferritin and liver MRI to detect iron accumulation early 7
• If systemic iron loading occurs, use phlebotomy if tolerated; otherwise, chelation therapy is recommended 7

In children with gastrointestinal disorders:

• Those with malabsorption syndromes may have unpredictable iron absorption, making toxicity assessment more challenging 8
• Evaluate for celiac disease or inflammatory bowel disease if iron toxicity occurs with seemingly lower doses 8

Adjunctive Therapies for Severe Cases

Consider hemodialysis in life-threatening toxicity:

• Reserved for massive overdose with serum iron >2000 mcg/dL and failure of conservative therapy 5, 4
• May assist in rapidly decreasing serum iron concentration and improving clinical status 5

Surgical intervention:

• Gastrotomy for removal of iron tablets is indicated only when large numbers of tablets form concretions visible on imaging and cannot be removed by lavage or whole-bowel irrigation 4

Common Pitfalls to Avoid

• Do not rely solely on initial serum iron levels drawn <4 hours post-ingestion, as they may not reflect peak absorption 3, 2
• Do not delay deferoxamine in symptomatic patients while waiting for serum iron results 4, 2
• Do not use oral deferoxamine for systemic chelation; it is ineffective and only useful in lavage solutions 2
• Do not discontinue deferoxamine prematurely before serum iron normalizes and symptoms resolve, as rebound toxicity can occur 5, 2
• Recognize that hepatotoxicity can occur even with lower serum iron levels (<500 mcg/dL) and may manifest 24-48 hours post-ingestion with elevated aminotransferases and coagulopathy 6

Monitoring for Late Complications

Assess for delayed hepatic injury:

• Monitor aminotransferases, bilirubin, and prothrombin time for 48-72 hours post-ingestion 6
• Hepatotoxicity is associated with high mortality and requires intensive supportive care 6

Screen for gastrointestinal scarring:

• Late sequelae include pyloric stenosis and bowel obstruction from scarring, which may manifest weeks after acute ingestion 4
• Arrange follow-up if persistent gastrointestinal symptoms develop 4