BNF for Children 2011-2012

BNFC 2011–2012 9.1.1 Iron-deficiency anaemias 443Treatment of iron-deficiency anaemia The oraldose of elemental iron to treat deficiency is 3–6 mg/kg(max. 200 mg) daily given in 2–3 divided doses. Ironsupplementation may also be required to produce anoptimum response to erythropoietins in iron-deficientchildren with chronic renal failure or in preterm neonates.(See also Prophylaxis of iron deficiency, below.)Prescribing Express the dose in terms of elemental iron andiron salt and select the most appropriate preparation; specifyboth the iron salt and formulation on the prescription. The ironcontent of artificial formula feeds should also be considered.Iron content of different iron saltsIron saltAmountContent offerrous ironFerrous fumarate 200 mg 65 mgFerrous gluconate 300 mg 35 mgFerrous sulphate 300 mg 60 mgFerrous sulphate, dried 200 mg 65 mgSodium feredetate 190 mg 27.5 mgTherapeutic response The haemoglobin concentrationshould rise by about 100–200 mg/100 mL (1–2 g/litre)per day or 2 g/100 mL (20 g/litre) over 3–4 weeks.When the haemoglobin is in the normal range, treatmentshould be continued for a further 3 months toreplenish the iron stores. Epithelial tissue changes suchas atrophic glossitis and koilonychia are usuallyimproved, but the response is often slow. The mostcommon reason for lack of response in children ispoor compliance; poor absorption is rare in children.Prophylaxis of iron deficiency In neonates, haemoglobinand haematocrit concentrations change rapidly.These changes are not due to iron deficiency and cannotbe corrected by iron supplementation. Similarly, neonatalanaemia resulting from repeated blood samplingdoes not respond to iron therapy.All babies, including preterm neonates, are born withsubstantial iron stores but these stores can becomedepleted unless dietary intake is adequate. All babiesrequire an iron intake of 400–700 nanograms daily tomaintain body stores. Iron in breast milk is wellabsorbed but that in artificial feeds or in cow’s milk isless so. Most artificial formula feeds are sufficientlyfortified with iron to prevent deficiency and their ironcontent should be taken into account when consideringfurther iron supplementation.Dose Prophylactic iron supplementation (elementaliron 5 mg daily) may be required in babies of lowbirth-weight who are solely breast-fed; supplementationis started 4–6 weeks after birth and continued untilmixed feeding is established.Infants with a poor diet may become anaemic in thesecond year of life, particularly if cow’s milk, rather thanfortified formula feed, is a major part of the diet.Compound preparations Some oral preparationscontain ascorbic acid to aid absorption of the iron,but the therapeutic advantage of such preparations isminimal and cost may be increased.There is no justification for the inclusion of other ingredients,such as the B group of vitamins, except folicacid for pregnant women, see p. 446.Side-effects Gastro-intestinal irritation can occur withiron salts. Nausea and epigastric pain are dose-related,but the relationship between dose and altered bowelhabit (constipation or diarrhoea) is less clear. Oral ironcan exacerbate diarrhoea in patients with inflammatorybowel disease.Iron preparations taken orally can be constipating andoccasionally lead to faecal impaction.If side-effects occur, the dose may be reduced; alternatively,another iron salt may be used, but an improvementin tolerance may simply be a result of a lowercontent of elemental iron. The incidence of side-effectsdue to ferrous sulphate is no greater than with other ironsalts when compared on the basis of equivalent amountsof elemental iron.Iron preparations are an important cause of accidentaloverdose in children and as little as 20 mg/kg of elementaliron can lead to symptoms of toxicity. For thetreatment of iron overdose, see Emergency Treatmentof Poisoning, p. 30.Counselling Although iron preparations are bestabsorbed on an empty stomach, they can be takenafter food to reduce gastro-intestinal side-effects; theymay discolour stools.FERROUS SULPHATECautions interactions: Appendix 1 (iron)Side-effects see notes aboveIndication and doseIron-deficiency anaemia, prophylaxis of irondeficiency see notes above and preparationsFerrous Sulphate (Non-proprietary)Tablets, coated, dried ferrous sulphate 200 mg (65 mgiron), net price 28-tab pack = £1.15DoseChild 6–18 years prophylactic, 1 tablet daily; therapeutic,1 tablet 2–3 times daily, see notes aboveIronorm c Drops (Wallace Mfg)Oral drops, ferrous sulphate 125 mg (25 mg iron)/mL,net price 15 mL = £4.95DoseChild 1 month–6 years prophylactic 0.3 mL daily, butsee notes aboveChild 6–18 years prophylactic 0.6 mL dailyFERROUS FUMARATECautions interactions: Appendix 1 (iron)Side-effects see notes aboveIndication and doseIron-deficiency anaemia, prophylaxis of irondeficiency see notes above and preparationsFersaday c (Goldshield)Tablets, brown, f/c, ferrous fumarate 322 mg (100 mgiron). Net price 28-tab pack = 79pDoseChild 12–18 years prophylactic, 1 tablet daily; therapeutic,1 tablet twice daily9 Nutrition and blood