Which pediatric iron supplement brand do you recommend for a 2‑year‑old, 12‑kg toddler with iron‑deficiency anemia?

Recommended Iron Supplement for Your Toddler

For your 2-year-old, 12-kg toddler with iron-deficiency anemia, I recommend ferrous sulfate drops (25 mg elemental iron per mL) at a dose of 36 mg elemental iron once daily (approximately 1.4 mL), given on an empty stomach between meals. 1, 2

Why Ferrous Sulfate Is the Best Choice

Ferrous sulfate is the most effective and evidence-based iron formulation for treating pediatric iron-deficiency anemia. 2 A 2017 randomized trial in JAMA demonstrated that low-dose ferrous sulfate (3 mg/kg/day) produced significantly greater hemoglobin increases (1.0 g/dL more) and higher rates of complete anemia resolution (29% vs 6%) compared to iron polysaccharide complex in children aged 9-48 months. 2

Key Advantages of Ferrous Sulfate:

• Superior efficacy: Produces greater increases in hemoglobin, ferritin, and complete resolution of anemia compared to alternative formulations 2
• Most cost-effective: Widely available and inexpensive 3
• Standard of care: Recommended by CDC and most pediatric hematology specialists (84% prescribe it) 1, 4
• Well-tolerated at low doses: The once-daily 3 mg/kg regimen minimizes gastrointestinal side effects 2

Specific Dosing Instructions

For your 12-kg child:

• Dose: 36 mg elemental iron daily (3 mg/kg × 12 kg) 1, 2
• Volume: Approximately 1.4 mL of ferrous sulfate drops (25 mg/mL formulation) 1
• Frequency: Once daily 2
• Timing: Between meals on an empty stomach to maximize absorption 1

Administration Guidelines

Give the iron drops at least 2 hours before or 1 hour after meals, as food can reduce iron absorption by up to 50%. 5 Avoid giving iron with:

• Milk or dairy products 5
• Tea or coffee 5
• Calcium supplements 5

If your child experiences stomach upset, you may give the iron with a small amount of food, though this will reduce absorption somewhat. 1

Treatment Duration and Monitoring

Continue treatment for a full 3-month course: 1

1. After 4 weeks: Recheck hemoglobin. An increase of ≥1 g/dL confirms the diagnosis and adequate response 1
2. If responding: Continue for 2 additional months (total 3 months) to replenish iron stores 1
3. After completing treatment: Recheck hemoglobin, then again 6 months later 1

If no improvement after 4 weeks despite confirmed adherence and no acute illness, obtain additional testing (MCV, RDW, serum ferritin) to exclude other causes. 1

Expected Side Effects

Common mild gastrointestinal symptoms (nausea, loose stools, darker stools) should not prompt discontinuation. 1 The JAMA trial found that low-dose ferrous sulfate actually caused less diarrhea than iron polysaccharide complex (35% vs 58%). 2

Why Not Other Formulations?

• Iron polysaccharide complex: Inferior efficacy with lower hemoglobin increases and more diarrhea 2
• Ferrous fumarate: While containing more elemental iron per tablet (108 mg per 325 mg), it offers no proven advantage over ferrous sulfate for pediatric treatment and liquid formulations are less standardized 5
• IV iron (iron sucrose): Reserved only for malabsorption, intolerance to all oral formulations, or non-response to adequate oral therapy 6

Dietary Counseling

Concurrent dietary changes are essential to address the underlying inadequate iron intake: 1

• Limit cow's milk to <24 oz daily (excess milk is a major risk factor for iron deficiency) 7
• Offer iron-fortified cereals 7
• Include iron-rich foods (meat, beans, fortified grains) 7
• Avoid introducing cow's milk before 12 months of age 7

Common Pitfalls to Avoid

• Underdosing: Ensure you calculate based on elemental iron content (not total salt weight) 1
• Giving with meals: This dramatically reduces absorption 1, 5
• Stopping too early: The full 3-month course is needed to replenish stores, not just correct hemoglobin 1
• Not addressing diet: Iron supplementation alone without dietary modification sets up recurrence 1