It is important to find out the cause of iron deficiency. In children, it is often due to poor intake rather than blood loss. Therefore, the key to success in the management of IDA is proper nutritional counseling. Parents should be made to understand the need for a well balanced diet, particularly in growing children. Continuation of breast milk should be encouraged beyond 6 months, as bioavailability of iron in the breast milk is high. Restriction of milk to one pint a day, and introduction of iron rich weaning foods like nachani, jaggery, cereals, spinach, beans, meat, fruits etc. and iron fortified food should be advocated.

A) Oral iron therapy : This is the treatment of choice, as it is cheap, safe, effective and well tolerated. Parenteral administration is reserved for patient who are completely intolerant to oral iron or when compliance is poor. Various preparations available are shown in Table 5.

Ferrous salts are absorbed better than ferric salts. Of the ferrous salts, ferrous sulphate is most preferred because of its low cost.

Various types of preparation available are as follows :

Table 5: PERCENTAGE & AMOUNT OF IRON IN SOME COMMONLY USED IRON TABLETS

Preparation	Iron compound (mg) per tab	Elemental iron (mg) per tab	% of iron given
Ferrous fumarate	200	66	33
Ferrous gluconate	300	36	12
Ferrous sulphate (7H 2 O)	300	60	20
Ferrous sulphate (anhydrous)	200	74	37

• Uncoated tablets and sugar coated tablets : Least expensive but less effective as they get oxidized.
  
  
• Enteric coated tablets : More expensive, disintegrate only partially in gastric acidity. Side effect are minimal, therefore better compliance. However, if disintegration of the tablet does not take place, than it may not be effective.
  
  
• Liquid preparations : They include syrups and drops. Useful for children and infants but are expensive and deteriorate on storage.
  
  
• Combination of other nutrients : Ascorbic acid in the dose of 100mg/15mg elemental iron enhances absorption of 30%. But it is expensive and increases side effects.
  
  Dose/ duration : 4-6 mg/ kg/day of elemental iron is started and continued for three months after Hb returns to the normal so as to also replenish the deficiency of storage. For children effective dosage is 1.5-2.0 mg. of elemental iron/kg/body weight 3 times per day.
  
  Difficulty encountered with oral iron : Sub-optimal response may be due to
  
  • Poor compliance
  • reparation with poor content and absorption of iron
  • Malabsorption
  • Loss greater than intake as seen in telangiectasia, portal hypertension, piles etc.
  • Discontinuation of treatment after initial 3 - 4 weeks because of a feeling of well-being or due to gastrointestinal adverse side-effects
  • Concurrent protein, folic acid, B12 or other nutrients deficiencies
  • Incorrect diagnosis
    
    
  Response to Treatment : A positive response to treatment can be defined as a daily increase in Hemoglobin concentration of 0.1 - 0.3 g/dl or 1% rise in Hematocrit daily from fourth day onwards. Reticulocytes increase within 3 to 5 days of initiation of treatment, reaching a peak at 7 - 10 days. Hemoglobin is virtually normalized after two months of therapy. With onset of treatment, patient shows rapid subjective improvement with disappearance of fatigability, lassitude, pica and other non-specific symptoms even before there is increase in hemoglobin level.
  
  Side Effects : Side effects are probably related to dose and amount of elemental iron. They include gastrointestinal symptoms - heart burn, nausea, abdominal cramps, diarrhea, constipation, blackish discoloration of tongue and teeth etc.
  
  

B) Parenteral Iron Therapy :

This mode of administration should be resorted to only in cases where anemia persists due to the factors causing failure of oral iron therapy like

• Intolerance to oral iron therapy
• Non-compliance
• Loss of iron at a rate too rapid for the oral intake to compensate for the loss (e.g. hereditary hemorrhagic telangiectasia)
• Disorders of GI tract like ulcerative colitis, malabsorption,
• unable to maintain iron balance on treatment or hemodialysis
• Donating large amounts of blood for autotransfusion programme.
  
  

It includes both intramuscular and intravenous iron therapy. The preparation most popularly used is iron dextran, which contains 50 mg/ml of elemental iron.

Intramuscular iron administration : It is very painful and may cause serious allergic reactions. Hence, it is not used in children. IM injections are best given deep into the upper outer quadrant of gluteal region and skin should be laterally displaced before injection (Z tract technique) to prevent iron staining of the skin. A dose of 0.25 cc should be given as a test dose IM, and if there are no reactions after 1 hour, then full dose can be given.

Intravenous iron therapy :

• Infusion of iron dextran (diluted in ratio of 5 ml iron dextran complex in 100 ml of saline solution). Initially flow rate should be kept at 20 drops per minute for 5 minutes, if there are no side effects, then the rate may be increased to 40 - 60 drops per minute.
• Bolus iron dextran (diluted in a small volume).
  
  

Both are however given only after a prior sensitivity testing with intravenous test dose injection. Infusion therapy is associated with a higher incidence of adverse effects as compared to bolus treatment. Nevertheless, both forms of treatment are not spared from anaphylactic reactions. This must be taken as a word of caution against use of intravenous iron therapy.