Iron Supplementation for a 2-Year-Old with ARFID and Ferritin 21 µg/L
Yes, this child should receive oral iron supplementation at 3 mg/kg/day of elemental iron, given between meals, for at least 4 weeks with reassessment of hemoglobin at that time. 1, 2
Rationale for Treatment
Iron Status Assessment
- A ferritin of 21 µg/L in a 2-year-old indicates depleted iron stores, even though hemoglobin is currently normal 3
- Children aged 12-36 months have the highest risk of iron deficiency of any age group due to rapid growth and frequently inadequate dietary iron intake 3
- The reference range for ferritin in young children is 11-307 µg/L, but values below 15 µg/L confirm iron deficiency, and values in the low-normal range (15-30 µg/L) suggest inadequate stores 3, 2
- ARFID significantly increases the risk of nutritional deficiencies, including iron deficiency, due to limited volume or variety of food intake 4, 5
High-Risk Population
- This child meets multiple criteria for high-risk screening and intervention: 3, 2
- Age 2 years (peak risk period for iron deficiency)
- ARFID with restricted dietary intake
- Likely inadequate iron from complementary foods given the feeding disorder
- Ferritin in the low-normal range indicating marginal iron stores
Treatment Protocol
Dosing and Administration:
- Administer 3 mg/kg/day of elemental iron (ferrous sulfate drops) between meals to maximize absorption 1, 2
- Food reduces iron bioavailability by up to 50%, so timing between meals is critical 1
- Pair with vitamin C-rich foods or juice to enhance non-heme iron absorption 3, 1
Monitoring Schedule:
- Recheck hemoglobin after 4 weeks of treatment 1, 2
- A positive response is defined as hemoglobin increase ≥1 g/dL (or hematocrit ≥3%) 1, 2
- If response is confirmed, continue iron for an additional 2 months (total ≈3 months) to replenish iron stores 1, 2
- Perform final hemoglobin check at end of therapy and repeat screening ≈6 months later 2
If No Response After 4 Weeks:
- Obtain mean corpuscular volume (MCV), red-cell distribution width (RDW), and repeat ferritin 2
- Ferritin ≤15 µg/L confirms iron deficiency; >15 µg/L suggests alternative etiology (thalassemia trait, chronic inflammation, lead exposure) 2
Critical Considerations for ARFID
Dietary Counseling Challenges
- Standard dietary recommendations (iron-fortified cereals, pureed meats, vitamin C-rich foods) may be difficult to implement in a child with ARFID due to sensory sensitivities, fear of adverse consequences, or lack of interest in eating 4, 5, 6
- Supplementation becomes even more critical when dietary modification is limited by the underlying feeding disorder 4, 7
- Consider referral for cognitive behavioral therapy (CBT) and/or family-based therapy (FBT) to address the ARFID, which may improve long-term dietary iron intake 4, 5, 7
Common Pitfalls to Avoid
- Do not delay treatment waiting for hemoglobin to drop; ferritin of 21 µg/L indicates the child is already iron-depleted and at risk for progression to anemia 3, 2
- Do not give iron with meals or milk, as this significantly reduces absorption 1
- Limit cow's milk to <24 oz/day (if consumed), as excessive milk intake is a risk factor for iron deficiency 3, 1
- Mild gastrointestinal symptoms (nausea, constipation, diarrhea) are common but should not prompt discontinuation unless severe 1, 8
- Do not over-supplement once iron stores are replete, as this can compromise growth and disturb gut microbiota 8
Multidisciplinary Approach
- Given the ARFID diagnosis, this child requires coordinated care between primary care, nutrition, and mental health services 4, 5
- Screen for other nutritional deficiencies common in ARFID (vitamins A, C, D, E, zinc) 7
- Monitor growth parameters and psychosocial functioning as part of comprehensive ARFID management 4, 5, 9