Treatment of Iron Deficiency in a 2-Year-Old Child
Treat with oral ferrous sulfate at 3 mg/kg per day of elemental iron, administered between meals, and provide dietary counseling to address underlying low iron intake. 1, 2
Initial Treatment Protocol
Start oral iron supplementation immediately at 3 mg/kg per day of elemental iron, given between meals to maximize absorption. 1, 2 This is the standard first-line treatment recommended by the Centers for Disease Control and Prevention for presumptive iron deficiency anemia in young children.
Key Administration Details:
- Give iron between meals (not with food) as food can reduce iron absorption by up to 50%. 2
- Use ferrous sulfate as the preferred formulation—it is the most cost-effective and provides known amounts of elemental iron. 2
- Avoid iron polysaccharide complex despite being more expensive, as it is no better tolerated and may be less effective. 2
- Do not add ascorbic acid (vitamin C supplements with the iron dose) as it does not improve ferrous iron absorption. 2
Confirming the Diagnosis
Recheck hemoglobin in 4 weeks. 1, 2 An increase in hemoglobin ≥1 g/dL or hematocrit ≥3% confirms the diagnosis of iron deficiency anemia. 1, 3
If Treatment Fails:
If anemia does not respond after 4 weeks despite compliance and absence of acute illness, further evaluate with additional laboratory tests including MCV, RDW, and serum ferritin. 1 A serum ferritin <15 μg/L confirms iron deficiency, while >15 μg/L suggests another cause. 1
Duration of Treatment
Continue iron supplementation for 2 additional months after confirming response (total of 3 months) to replenish iron stores, then recheck hemoglobin/hematocrit. 1, 2 Reassess hemoglobin approximately 6 months after successful treatment completion. 1
Essential Dietary Modifications
Limit cow's milk to no more than 24 oz (720 mL) per day. 1, 4 Excessive milk intake is a major contributor to iron deficiency by displacing iron-rich foods and potentially causing occult blood loss.
Dietary Recommendations:
- Provide iron-fortified cereals (two or more servings daily can meet iron requirements). 1
- Include vitamin C-rich foods (fruits, vegetables, or juice) with meals to improve iron absorption. 1
- Introduce plain, pureed meats as a source of heme iron. 1
Common Pitfalls to Avoid
Do not delay treatment while waiting for ferritin results in a 2-year-old with suspected iron deficiency anemia, as this age group (9 months to 3 years) is at highest risk due to rapid growth and frequently inadequate dietary iron intake. 4, 5
If the child has difficulty tolerating oral iron, start with smaller, more frequent doses and gradually increase to the target dose rather than discontinuing treatment. 2 Gastrointestinal side effects are common but can be managed by adjusting the dosing schedule.
Do not administer iron within 2 hours before or 1 hour after meals, and avoid aluminum-based phosphate binders which can reduce iron absorption. 2
When Underlying Causes Must Be Addressed
Failure to address the root cause of iron deficiency will lead to recurrence. 2 The most common causes in 2-year-olds include:
- Excessive cow's milk consumption (>24 oz/day) 1
- Inadequate dietary iron intake 1, 5
- Limited access to iron-rich foods 1
Dietary counseling is mandatory and should be reinforced at the 4-week follow-up visit and throughout treatment. 1, 2