eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Toxicology

Toxicity, Iron: Follow-up

Author: Jennifer S Boyle, MD, PharmD, Fellow in Toxicology, University of Virginia Health System
Coauthor(s): David T Lawrence, DO, Assistant Professor, Department of Emergency Medicine, Division of Medical Toxicology, University of Virginia School of Medicine; Christopher P Holstege, MD, Associate Professor of Emergency Medicine and Pediatrics, University of Virginia; Director, Division of Medical Toxicology, Center of Clinical Toxicology; Medical Director, Blue Ridge Poison Ctr, Associate Medical Toxicology Fellowship Director, VA Dept of Health; Kathryn Clark Emery, MD, Associate Professor, Department of Pediatrics, University of Colorado Health Sciences Center; Consulting Staff, Department of Emergency Medicine, Children's Hospital of Denver
Contributor Information and Disclosures

Updated: Jun 24, 2009

Follow-up

Further Inpatient Care

  • Patients with acute iron poisoning have developed Yersinia enterocolitica infection or sepsis as a complication of their clinical course.
  • Yersinia requires iron as a growth factor. Deferoxamine acts to solubilize iron and aid in intracellular entry for Yersinia.
  • Suspect Yersinia infection in patients who develop abdominal pain, fever, and diarrhea following resolution of iron toxicity.

Further Outpatient Care

Transfer

  • Treat patients who present with signs and symptoms of significant iron poisoning, such as metabolic acidosis, potential hemodynamic instability, and/or lethargy, in a pediatric ICU.

Deterrence/Prevention

  • Many ingestions are accidental. As for any medication, preventive measures include keeping the bottles of iron supplements, with childproof tops, inaccessible to children. Changing the appearance of prenatal vitamins to make them look less like candy has been considered. This would be ideal.
  • In 1997, the US Food and Drug Administration (FDA) issued a regulation requiring unit-dose packaging for iron-containing products with 30 mg or more of iron per dosage unit. Because of the time and effort to open unit-dose packages, the FDA believes this packaging limits unintentional access to children. This requirement is in addition to existing Consumer Product Safety Commission regulations that require child-resistant packaging for most iron-containing products. In 2003, this requirement was rescinded because of a lawsuit in which the National Health Alliance charged that the FDA had no jurisdiction over the packaging of dietary supplements.

Complications

  • Infectious -Yersinia enterocolitica septicemia
  • Pulmonary - Acute respiratory distress syndrome (ARDS)
  • Gastrointestinal - Fulminant hepatic failure, hepatic cirrhosis, pyloric or duodenal stenosis

Prognosis

  • If a patient does not develop symptoms of iron toxicity within 6 hours of ingestion, iron toxicity is unlikely to develop. Expect clinical toxicity following an ingestion of 20 mg/kg of elemental iron. Expect systemic toxicity with an ingestion of 60 mg/kg. Ingestion of more than 250 mg/kg of elemental iron is potentially lethal.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Do not be falsely reassured by a patient's clinical improvement. This may not represent recovery. Many patients experience a quiescent phase before progressing to profound iron toxicity.
  • Do not wait for a confirmatory iron level before initiating treatment in a patient who shows signs of severe toxicity. Also, do not be falsely reassured by a level that is drawn later in the course of toxicity. Treat the patient according to their clinical situation and not according to the serum iron level.
  • Be sure to include iron toxicity in the differential for unexplained metabolic acidosis, vomiting, diarrhea, and GI bleeding.
 


More on Toxicity, Iron

Overview: Toxicity, Iron
Differential Diagnoses & Workup: Toxicity, Iron
Treatment & Medication: Toxicity, Iron
Follow-up: Toxicity, Iron
Multimedia: Toxicity, Iron
References
[ CLOSE WINDOW ]

References

  1. Bronstein AC, Spyker DA, Cantilena LR Jr, Green JL, Rumack BH, Heard SE. 2007 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 25th Annual Report. Clin Toxicol (Phila). Dec 2008;46(10):927-1057. [Medline].

  2. [Best Evidence] Ziegler EE, Nelson SE, Jeter JM. Iron supplementation of breastfed infants from an early age. Am J Clin Nutr. Feb 2009;89(2):525-32. [Medline].

  3. Juurlink DN, Tenenbein M, Koren G, Redelmeier DA. Iron poisoning in young children: association with the birth of a sibling. CMAJ. Jun 10 2003;168(12):1539-42. [Medline].

  4. [Guideline] Manoguerra AS, Erdman AR, Booze LL, et al. Iron ingestion: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2005;43(6):553-70. [Medline].

  5. Bryant SM, Leikin JB. Iron. Critical Care Toxicology. 2005;687-693.

  6. Desferal (deferoxamine mesylate) [package insert]. East hanover, NJ: Novartis Pharmaceuticals Corporation; 2007. [Full Text].

  7. Eldridge DL, Holstege CP. Utilizing the laboratory in the poisoned patient. Clin Lab Med. Mar 2006;26(1):13-30, vii. [Medline].

  8. Engle JP, Polin KS, Stile IL. Acute iron intoxication: treatment controversies. Drug Intell Clin Pharm. Feb 1987;21(2):153-9. [Medline].

  9. Fine JS. Iron poisoning. Curr Probl Pediatr. Mar 2000;30(3):71-90. [Medline].

  10. Jacobs J, Greene H, Gendel BR. Acute iron intoxication. N Engl J Med. Nov 18 1965;273(21):1124-7. [Medline].

  11. Madiwale T, Liebelt E. Iron: not a benign therapeutic drug. Curr Opin Pediatr. Apr 2006;18(2):174-9. [Medline].

  12. McGuigan MA. Acute iron poisoning. Pediatr Ann. Jan 1996;25(1):33-8. [Medline].

  13. Perrone J. Iron. Goldfrank's Toxicologic Emergencies. 2006;629-637.

  14. Siff JE, Meldon SW, Tomassoni AJ. Usefulness of the total iron binding capacity in the evaluation and treatment of acute iron overdose. Ann Emerg Med. Jan 1999;33(1):73-6. [Medline].

  15. Tenenbein M. Position statement: whole bowel irrigation. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. J Toxicol Clin Toxicol. 1997;35(7):753-62. [Medline].

  16. Tenenbein M. Whole bowel irrigation in iron poisoning. J Pediatr. Jul 1987;111(1):142-5. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

iron toxicity, iron poisoning, ferrous sulfate tablets, ferrous sulfate, ferrous gluconate, ferrous fumarate, ferrous lactate, ferrous chloride, metabolic acidosis, hemorrhagic vomiting, diarrhea, abdominal pain, hepatic failure, pyloric obstruction, hepatic cirrhosis, multivitamin ingestion, treatment, diagnosis

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Jennifer S Boyle, MD, PharmD, Fellow in Toxicology, University of Virginia Health System
Disclosure: Nothing to disclose.

Coauthor(s)

David T Lawrence, DO, Assistant Professor, Department of Emergency Medicine, Division of Medical Toxicology, University of Virginia School of Medicine
David T Lawrence, DO is a member of the following medical societies: American College of Emergency Physicians and American College of Medical Toxicology
Disclosure: Nothing to disclose.

Christopher P Holstege, MD, Associate Professor of Emergency Medicine and Pediatrics, University of Virginia; Director, Division of Medical Toxicology, Center of Clinical Toxicology; Medical Director, Blue Ridge Poison Ctr, Associate Medical Toxicology Fellowship Director, VA Dept of Health
Christopher P Holstege, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American Association for the Advancement of Science, American College of Emergency Physicians, American College of Medical Toxicology, American Medical Association, Medical Society of Virginia, Society for Academic Emergency Medicine, Society of Toxicology, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Kathryn Clark Emery, MD, Associate Professor, Department of Pediatrics, University of Colorado Health Sciences Center; Consulting Staff, Department of Emergency Medicine, Children's Hospital of Denver
Kathryn Clark Emery, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Medical Editor

Halim Hennes, MD, MS, Pediatric Emergency Medicine Research Director, Professor, Departments of Pediatrics and Emergency Medicine, Medical College of Wisconsin
Halim Hennes, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Jeffrey R Tucker, MD, Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, University of Connecticut and Connecticut Children's Medical Center
Jeffrey R Tucker, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Pediatrics, and Massachusetts Medical Society
Disclosure: Merck Salary Employment

CME Editor

Paul D Petry, DO, FACOP, FAAP, Consulting Staff, Freeman Pediatric Care, Freeman Health System
Paul D Petry, DO, FACOP, FAAP is a member of the following medical societies: American Academy of Osteopathy, American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association
Disclosure: Nothing to disclose.

Chief Editor

Timothy E Corden, MD, Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin
Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, and Wisconsin Medical Society
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.