Iron Poisoning (Overdose) In Children

Iron poisoning occurs when a person, usually a child, swallows a large number of iron-containing pills, most often vitamins.

Call a doctor, local poison control center, or go directly to the closest hospital's emergency department if you suspect a child has swallowed iron-containing vitamins, even if the child shows no symptoms. Bring the container that lists the strengths with you.

• If you find a child among iron pills or pill containers, or a child tells you he or she has swallowed pills, take the child to a hospital's emergency department because symptoms may not have had time to develop.
• Iron poisoning occurs when a person, usually a child, swallows a large number of iron-containing pills, most often vitamins.
• Acute iron poisoning mainly involves children younger than 6 years who swallow pediatric or adult vitamins containing iron. These children may not be able or willing to tell you what and how much they swallowed.
• Iron salt is available in multiple preparations. For instance, ferrous sulfate is available as
  • drops,
  • syrup,
  • elixir,
  • capsules, and
  • tablets.

Iron preparations are widely used and are available without a prescription and may be contained in bottles with or without child-resistant closures.

• The amount of iron that will cause poisoning depends upon the size of the child. An 8-year-old may show no symptoms from an amount that would cause serious symptoms in a 3-year-old. Symptoms appear at doses greater than 10 mg/kg (based on the bodyweight of the child).
• Iron is available in different oral forms.
• A child may show no symptoms after eating several pills that might have looked like candy. The only evidence may be an opened vitamin bottle. If you know or even suspect, that a child has eaten tablets, you should consult a hospital's emergency department or poison control center regarding a possible iron poisoning immediately.

Call a doctor, local poison control center, or go directly to the closest hospital's emergency department if you suspect a child has swallowed iron-containing vitamins, even if the child shows no symptoms. Bring the container that lists the strengths with you.

If you find a child among iron pills or pill containers, or a child tells you that he or she has swallowed pills, take the child to a hospital's emergency department because symptoms may not have had time to develop.

Symptoms of iron poisoning usually become evident within 6 hours after an excessive amount of iron is swallowed.

1. Iron corrodes the intestinal lining and is a direct irritant to the stomach.
2. People with iron poisoning can have signs and symptoms such as:
   • Severe vomiting
   • Diarrhea
   • Abdominal pain
   • Dehydration and lethargy if not treated adequately
3. A child's vomit or stool may be bloody.
4. Often, after supportive care, the gastrointestinal symptoms appear to improve 6-24 hours after their onset.
5. If profound poisoning is inadequately treated, shock and death can occur.

The amount of iron ingested may give a clue to potential toxicity. The therapeutic dose for iron deficiency anemia is 3-6 mg/kg/day. Toxic effects begin to occur at doses above 10-20 mg/kg of elemental iron. Ingestions of more than 50 mg/kg of elemental iron are associated with severe toxicity.

• A 325-mg tablet of ferrous sulfate has 65 mg (20%) of elemental iron
• A 325-mg tablet of ferrous gluconate has 39 mg (12%) of elemental iron
• A 325-mg tablet of ferrous fumarate has 107.25 mg (33%) of elemental iron

Intentional overdose can occur among adults but is rare.

Iron pills, especially children's multivitamin tablets, can look like candy to children.

• Full recovery is likely for children or adults who show no symptoms for at least 6 hours after swallowing pills. Those with symptoms may be ill and require more aggressive treatment.
• Iron poisoning can progress through several stages. A late, or hepatic stage, develops 2-5 days after ingestion. The person may have elevated liver enzymes, possibly ultimately resulting in liver failure.
• Another late stage involves gastrointestinal scarring. Some 4-6 weeks after ingestion, the final stage manifests with early satiety (fullness after eating) or nausea from GI scarring and obstruction.

A doctor diagnoses iron poisoning by observing the child. A normal physical exam and no symptoms for 6 hours indicates that the child experienced either little poisoning or did not eat any iron-containing substances.

If you can, tell the doctor the type of iron supplement and the number of tablets swallowed.

The doctor order blood tests for the child to determine these levels:

• Iron
• White blood cell count
• Serum glucose (blood sugar)

The doctor may perform an X-ray of the child's abdomen to confirm there are iron pills in the gastrointestinal tract, although sometimes they are there and not seen.

Laboratory and imaging tests are not usually sensitive enough to detect poisoning. Some tests are also too slow to affect the diagnosis and management of iron poisoning.

Once the doctor makes sure the child is breathing normally, the child likely will have his or her whole bowel cleaned by drinking a strong laxative fluid.

Severe poisonings will require IV chelation therapy - a series of IVs containing deferoxamine mesylate (Desferal), a chemical that binds to iron in a cell and is then excreted in urine.

• Deferoxamine can be administered by IV or injection, but the IV route is preferred for easier dose adjustment. A change in urine color (to a red-orange) and low blood pressure are common side effects with deferoxamine treatment.
• Usually children require no more than 24 hours of therapy.

Orogastric lavage, or pumping of the stomach, can be considered, but it is generally only helpful if performed within 1 hour of swallowing the pills. Insertion of the tube can cause complications, and many pills may not fit through the ports of a lavage tube if they are not disintegrated.

If ingestion of other medications is suspected, the physician may give the child activated charcoal to drink. Activated charcoal does not bind to iron but may be useful in adsorbing other medications.

If you suspect a child has accidentally swallowed iron tablets, call a doctor or poison control center immediately. You can locate your regional poison control center phone number before an emergency by checking the Website of the American Association of Poison Control Centers.

• Do not attempt to induce vomiting, either manually or with syrup of ipecac. This will make it more difficult to assess whether a child is truly iron toxic.
• Bring the medicine containers along with you to the hospital.

• Keep medications where children cannot get to them.
• Childproof caps are not a guarantee that children are safe from poisoning.
• Educate children that unknown pills are not candy and can be harmful.