What is the recommended dose of Desferoxamine (Deferoxamine) for a pediatric patient under 6 years old with suspected iron toxicity?

Deferoxamine Dosing for Acute Iron Toxicity in Pediatric Patients Under 6 Years

For acute iron toxicity in pediatric patients under 6 years old, administer deferoxamine at 15 mg/kg/hour by continuous intravenous infusion, not to exceed 6000 mg in 24 hours, using the IV route only for patients in cardiovascular collapse. 1

Route Selection Based on Clinical Status

For hemodynamically stable patients:

• Use intramuscular administration as the preferred route 1
• Initial dose: 1000 mg IM, followed by 500 mg every 4 hours for two doses 1
• Subsequent doses of 500 mg may be given every 4-12 hours based on clinical response 1

For patients in shock or cardiovascular collapse:

• Intravenous route is mandatory 1
• Initial 1000 mg dose must not exceed 15 mg/kg/hour infusion rate 1
• After the first 1000 mg, subsequent dosing must be slower, not exceeding 125 mg/hour 1
• Follow with 500 mg over 4 hours for two doses, then 500 mg every 4-12 hours as needed 1

Critical Dosing Limits and Safety

The absolute maximum is 6000 mg in 24 hours regardless of route or clinical severity. 1 This ceiling exists because excessive deferoxamine doses cause serious pulmonary toxicity, including acute respiratory distress syndrome, particularly when high intravenous doses are prolonged beyond 24 hours. 2, 3

Key safety considerations specific to young children:

• Growth monitoring is essential, as serious adverse events occur particularly when deferoxamine doses are high relative to iron burden 4
• Ophthalmologic and audiological testing should be performed, as sensorineural deafness and visual disturbances are recognized toxicities 4
• Skeletal abnormalities and growth retardation are documented adverse effects in pediatric patients 4

Administration Technique

For IV administration:

• Reconstitute with sterile water: 500 mg vial with 5 mL yields 95 mg/mL concentration 1
• Add reconstituted solution to physiologic saline, glucose in water, or Ringer's lactate 1
• Must use within 3 hours of reconstitution, or within 24 hours if prepared under validated aseptic conditions 1
• Never refrigerate reconstituted solution 1

For IM administration:

• Reconstitute with sterile water: 500 mg vial with 2 mL yields 213 mg/mL concentration 1
• Switch from IV to IM route as soon as the patient's clinical condition permits 1

Monitoring During Acute Treatment

Clinical endpoints to guide therapy duration:

• Serum iron concentration should decrease substantially within 8-24 hours of initiating therapy 5, 6
• In documented cases, serum iron dropped from 14,250 mcg/dL to 657 mcg/dL within 9 hours of IV deferoxamine 5
• Another case showed reduction from 2150 to 160 mcg/dL at 24 hours 6

Discontinuation criteria:

• Stop deferoxamine when serum iron normalizes and clinical toxicity resolves 5
• Typical duration is 24-48 hours for acute iron poisoning 5, 3
• Prolonging therapy beyond what is necessary increases risk of deferoxamine-induced pulmonary toxicity 2, 3

Common Pitfalls to Avoid

Do not exceed 15 mg/kg/hour for the initial 1000 mg dose - this is the maximum safe infusion rate for the first dose, with subsequent doses requiring even slower rates (≤125 mg/hour). 1 Faster rates increase cardiovascular toxicity risk. 2

Do not continue deferoxamine unnecessarily beyond 24-48 hours - the acute respiratory distress syndrome risk increases with prolonged high-dose IV administration. 2, 3 Target the initial high serum iron levels aggressively, then discontinue once iron is adequately chelated. 3

Do not use deferoxamine concurrently with blood transfusion - this can lead to errors in interpreting side effects such as rash, anaphylaxis, and hypotension. 1

Watch for infection risk - Yersinia and Klebsiella infections have been reported in patients treated with deferoxamine. 4