According to current pediatric nutrition guidelines, what are the recommended daily elemental iron supplementation amounts for each age group from infants to adolescents?

Iron Supplementation Requirements in Pediatrics: Birth Through Adolescence

Infants (0-12 Months)

For exclusively breastfed term infants, no iron supplementation is needed until 6 months of age, at which point 1 mg/kg/day of elemental iron should be provided if iron-rich complementary foods are insufficient. 1

Term, Normal Birth Weight Infants

Breastfed infants:

• 0-6 months: No supplementation needed; healthy term infants are self-sufficient due to iron redistribution from hemoglobin to stores 2
• 6-12 months: If iron-rich complementary foods provide less than 1 mg/kg/day, give 1 mg/kg/day of iron drops 1
• Introduce iron-fortified infant cereal at 4-6 months; two or more servings daily can meet iron requirements 1

Formula-fed infants:

• Use only iron-fortified formula (4-8 mg/L or 0.6-1.2 mg/kg/day) from birth through 12 months 3
• Never use low-iron milks (cow's milk, goat's milk, soy milk) before 12 months 1

Preterm and Low Birth Weight Infants

For preterm or low birth weight breastfed infants, initiate 2-4 mg/kg/day of iron drops (maximum 15 mg/day) starting at 1 month of age and continue until 12 months. 1, 4

• Marginally low birth weight infants (2000-2500 g) require 1-2 mg/kg/day 3
• These higher requirements reflect increased needs for catch-up growth and lower iron stores at birth 2

Preschool Children (1-5 Years)

Children aged 1-5 years should receive iron primarily through diet, with iron-fortified foods and meat products as key sources. 1

• Limit cow's milk, goat's milk, or soy milk to maximum 24 oz daily to prevent interference with iron absorption 1, 4
• Encourage vitamin C-rich foods with meals to enhance iron absorption 1, 4
• Iron requirements at 6-12 months (0.9-1.3 mg/kg body weight) are the highest per kilogram of any life period 2

School-Age Children and Adolescents (6+ Years)

Adolescents require 2 portions of meat products daily or equivalent iron-rich foods to meet their elevated iron needs from rapid growth and, in girls, menstrual losses. 5

Dietary Recommendations

• 7-12 years: Consume 100-150 grams per day of meat products, or at least 300 mL daily of growing-up milk if meat intake is insufficient 5
• Adolescent girls: Particularly vulnerable due to menstruation and rapid growth; require aggressive dietary counseling 6, 4
• Iron requirements increase substantially during adolescence due to blood volume expansion and muscular development 7

Supplementation Indications

For adolescents with documented iron deficiency, the optimal oral dose is 3-6 mg/kg/day of elemental iron (approximately 120-240 mg daily for a typical 40 kg child). 6

• Standard treatment for iron deficiency anemia: 2-3 mg/kg/day of elemental iron in divided doses 4
• Ferrous sulfate is the preferred formulation due to better clinical response, fewer side effects, and cost-effectiveness 4
• Administer between meals or at bedtime for optimal absorption; food reduces absorption by up to 50% 4

Special Populations Requiring Parenteral Iron

Parenteral iron should be reserved for oral intolerance, malabsorption, or failed oral therapy after 3 months of adequate treatment. 6, 8

Parenteral Dosing

• Children on parenteral nutrition: 50-100 mcg/kg/day (maximum 5 mg/day) 6, 4
• Iron sucrose (preferred): Most studied in children with best safety profile; 200 mg IV over 60 minutes every 2-3 weeks (maximum 300 mg per dose, 1000 mg total) 8
• No test dose required for iron sucrose, unlike iron dextran which carries black-box warning 8

Monitoring and Common Pitfalls

Measure hemoglobin after 1 month of oral iron therapy; adequate response is defined as ≥1.0 g/dL rise with normalization of ferritin and transferrin saturation. 4

Critical Screening Recommendations

• High-risk populations (low-income, WIC-eligible, migrant, refugee children): Screen at 9-12 months, 6 months later, then annually ages 2-5 years 1
• Standard-risk populations: Selective screening only for those with risk factors 1

Key Pitfalls to Avoid

• Excessive cow's milk (>24 oz daily) interferes with iron absorption and contributes to deficiency 4
• Aluminum-based phosphate binders reduce iron absorption 4
• Exceeding recommended parenteral doses can cause hepatocellular damage 4
• Never administer IV iron to patients with active infection due to inflammation and bacterial growth concerns 8