Iron Ingestion: an Evidence-Based Consensus Guideline for Out-of-Hospital Management

Abstract

From 1983 to 1991, iron caused over 30% of the deaths from accidental ingestion of drug products by children. An evidence-based expert consensus process was used to create this guideline. Relevant articles were abstracted by a trained physician researcher. The first draft of the guideline was created by the primary author. The entire panel discussed and refined the guideline before its distribution to secondary reviewers for comment. The panel then made changes in response to comments received. The objective of this guideline is to assist poison center personnel in the appropriate out-of-hospital triage and initial management of patients with suspected ingestions of iron by 1) describing the manner in which an ingestion of iron might be managed, 2) identifying the key decision elements in managing cases of iron ingestion, 3) providing clear and practical recommendations that reflect the current state of knowledge, and 4) identifying needs for research. This guideline applies to ingestion of iron alone and is based on an assessment of current scientific and clinical information. The expert consensus panel recognizes that specific patient care decisions may be at variance with this guideline and are the prerogative of the patient and the health professionals providing care, considering all of the circumstances involved. The panel's recommendations follow; the grade of recommendation is in parentheses. 1) Patients with stated or suspected self-harm or who are victims of malicious administration of an iron product should be referred to an acute care medical facility immediately. This activity should be guided by local poison center procedures. In general, this should occur regardless of the amount ingested (Grade D). 2) Pediatric or adult patients with a known ingestion of 40 mg/kg or greater of elemental iron in the form of adult ferrous salt formulations or who have severe or persistent symptoms related to iron ingestion should be referred to a healthcare facility for medical evaluation. Patients who have ingested less than 40 mg/kg of elemental iron and who are having mild symptoms can be observed at home. Mild symptoms such as vomiting and diarrhea occur frequently. These mild symptoms should not necessarily prompt referral to a healthcare facility. Patients with more serious symptoms, such as persistent vomiting and diarrhea, alterations in level of consciousness, hematemesis, and bloody diarrhea require referral. The same dose threshold should be used for pregnant women, however, when calculating the mg/kg dose ingested, the pre-pregnancy weight of the woman should be used (Grade C). 3) Patients with ingestions of children's chewable vitamins plus iron should be observed at home with appropriate follow-up. The presence of diarrhea should not be the sole indicator for referral as these products are often sweetened with sorbitol. Children may need referral for the management of dehydration if vomiting or diarrhea is severe or prolonged (Grade C). 4) Patients with unintentional ingestions of carbonyl iron or polys...

Dietary iron intake, iron status, and gestational diabetes

“…The majority of iron supplements contain nonheme iron in the form of ferrous and ferric iron salts, such as ferrous sulfate, ferric sulfate, and ferrous fumarate (18,40). The effects of iron supplementation on the risk of GDM have been examined in 2 large randomized control trials (34,36) (Table 1).…”

Iron Intoxication in a Dog Consequent to the Ingestion of Oxygen Absorber Sachets in Pet Treat Packaging

“…Early signs of iron intoxication include vomiting, diarrhea, abdominal pain, lethargy, and GI hemorrhage with possible hemodynamic compromise. Progressive cellular damage results in metabolic acidosis, hepatic damage and coagulopathy, capillary leak syndrome, shock, and death [2,4,8]. In rare cases, gastric outflow obstruction due to stricture formation occurs 2-8 weeks following ingestion [2].…”

“…Ingestions of less than 5-20 mg/kg of elemental iron typically result in mild clinical signs but are not likely to result in significant toxicosis [4,9,10]. Ingestions between 20 and 60 mg/kg of elemental iron can develop mild to moderate clinical signs, necessitating treatment or monitoring [2,4,11]. Ingestions greater than 60 mg/ kg can result in serious poisoning or death.…”

“…Ingestions of more than 20-40 mg/kg elemental iron or, in cases such as this where the amount of elemental iron is not known and clinical signs are visible, obtaining serum iron concentrations is warranted [2,4]. In oral overdose, peak concentrations of iron occur 2-6 h following ingestion, depending on the formulation.…”

“…Reported sources of unintentional iron intoxication in humans and animals include prenatal vitamins, multi-vitamins with iron, iron supplements (prescription or OTC), or, less commonly ferric chloride, parenteral iron, iron-based slug bait and fertilizers, and reduced-iron containing products such as instant hand/ foot warmers [2][3][4]. Reduced iron, the active ingredient believed to be in iron-based oxygen scavengers, is reported to have poor solubility in water and weak acids, which likely results in low oral bioavailability.…”