Pediatric Iron Toxicity Treatment & Management

Updated: Aug 04, 2020
  • Author: Christopher P Holstege, MD; Chief Editor: Stephen L Thornton, MD  more...
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Treatment

Approach Considerations

Asymptomatic patients may be monitored at home in collaboration with the local poison control center. Observation at home can also be used for patients who have ingested less than 40 mg/kg of elemental iron and who are having mild symptoms (eg, nausea, vomiting). Patients who have ingested children's chewable vitamins plus iron or carbonyl iron or polysaccharide-iron complex formulations should be observed at home with appropriate follow-up. [8]

Children who are symptomatic after an iron ingestion should have intravenous access established and laboratory monitoring for acidosis and anemia from hemorrhagic  gastrointestinal (GI) losses.

If an iron level is readily available from the laboratory, this should be obtained, and may need to be trended if the lab is obtained less than 6 hours after the ingestion.

Treatment with intravenous deferoxamine should be considered for iron levels >500 µg/dL, significant acidosis, or ongoing symptoms.

An abdominal x-ray may suggest the need for whole bowel irrigation if radioopaque fragments are visible. Endoscopic or surgical removal may be considered if retained iron tablets are evident after GI decontamination.

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Medical Care

The first step in treating a case of acute iron toxicity is to provide appropriate supportive care, with particular attention paid to fluid balance and cardiovascular stabilization. Initial treatment should also address the issue of preventing further absorption of iron by the GI tract.

Ipecac-induced emesis is not recommended. This is especially true in iron ingestion, as GI distress is an early finding in iron poisoning and is present in all potentially serious ingestions, and ipecac-induced vomiting may cloud the clinical picture. In any event, ipecac is rapidly becoming unavailable, and since 2003 is no longer recommended to be kept in the home by the American Academy of Pediatrics. [9]

Gastric lavage is not recommended because iron tablets are relatively large and become sticky in gastric fluid, making lavage unlikely to be of benefit. In addition, the physical placement of a lavage tube into friable mucosa may predispose to perforation. Activated charcoal is also not effective as it does not adsorb iron.

Whole bowel irrigation has been used to speed the passage of undissolved iron tablets through the GI tract, although there is no convincing evidence from clinical studies that it improves the outcome. [10] A polyethylene glycol electrolyte solution (eg, GoLYTELY) may be administered orally or nasogastrically at a rate of 250-500 mL/h for toddlers and preschoolers and 2 L/h for adolescents. It is recommended to start the irrigation slowly, increasing as tolerated, and provide antiemetics as needed. Continue irrigation until the repeat radiographic findings are negative or rectal effluent is clear.

Deferoxamine is the iron-chelating agent of choice. Deferoxamine binds absorbed iron, and the iron-deferoxamine complex is excreted in the urine. Deferoxamine does not bind iron in hemoglobin, myoglobin, or other iron-carrying proteins. Base the indications for using deferoxamine on both clinical and laboratory parameters. Indications for treatment include shock, altered mental status, persistent GI symptoms, metabolic acidosis, pills visible on radiographs, serum iron level greater than 500 µg/dL, or estimated dose greater than 50 mg/kg of elemental iron. Initiate chelation if a serum iron level is not available and symptoms are present.

Deferoxamine may be administered intramuscularly or intravenously. The intramuscular route is not recommended because it is painful and less iron is excreted compared with the intravenous route. Intravenously, deferoxamine is given as a continuous infusion. The standard dose is 15 mg/kg/h, with an initial dose administered for 6 hours. [11]  There is no role for oral deferoxamine.

No clear end point of therapy is noted; however, indications for cessation include significant resolution of shock and acidosis. Infusion of deferoxamine for 6-12 hours has been suggested for moderate toxicity. For severe toxicity, administer deferoxamine for 24 hours. Because these end points are arbitrary, observe the patient for the recurrence of toxicity 2-3 hours after the deferoxamine has been stopped.

Adverse effects from deferoxamine are unusual. Pulmonary toxicity (ie, acute respiratory distress syndrome [ARDS], tachypnea) has been described, especially if patients are treated with deferoxamine for more than 24 hours. Rate-related hypotension can occur. Therefore, monitor the patient while titrating the infusion rate upward to a final rate of 15 mg/kg/h, and ensure hydration has been initiated prior to starting the infusion. [12]

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Surgical Care

If retained iron tablets are evident after GI decontamination, consider endoscopy or surgery for their removal. Failure to remove the iron can result not only in continued iron absorption and exacerbation of systemic symptoms but also in gastric perforation and severe hemorrhage. Cases of GI perforation should prompt emergent surgical evaluation.

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Consultations

Regional poison control centers may be contacted for assistance in patient management (1-800-222-1222). In addition, consult an intensivist for help in managing the moderately to severely ill child. Admission to a pediatric intensive care unit is indicated for patients who present with signs and symptoms of significant iron poisoning, such as metabolic acidosis, potential hemodynamic instability, and/or lethargy.

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Complications

As mentioned above, treatment with deferoxamine has been associated with ARDS, albeit in rare cases.  Patient should be monitored for signs of respiratory distress or increased work of breathing during their treatment.

After treatment with deferoxamine, certain bacterial overgrowth may occur. Yersinia enterocolitica septicemia has been reported after iron overdoses. Yersinia uses iron as a siderophore for growth and its growth is further enhanced by treatment with deferoxamine. [13]

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Prevention

Most iron 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 was 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.

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