Iron poisoning, once an all-too-frequent tragedy in children, has become uncommon. This may underscore the success of a poisoning that has been prevented by interventions gleaned from poison center data and poison prevention advocacy. Blister packaging, smaller dosages, and education of parents and healthcare providers have led to a great decline in iron poisoning in the past decade. However, significant poisonings still occur, and when they do, they may not be managed as effectively as in the past because they less commonly occur and clinicians are less familiar with the problem. Clinicians must be vigilant for signs of serious iron poisoning and be ready to intervene if gastrointestinal (GI) symptoms are followed by acid–base disturbances, altered mental status, or hemodynamic compromise.
Iron salts such as ferrous sulfate have been used therapeutically for thousands of years and continues to be available, both with and without prescription, for the prevention and treatment of iron-deficiency anemia in patients of all ages. Despite this long history of use, the first reports of iron toxicity only occurred in the mid-20th century. Since then, numerous cases of iron poisoning and fatalities have been reported, mostly in children.56,57 In 1950, the manufacturer of "fersolate" included a package warning: "Excessive doses of iron can be dangerous. Do not leave these tablets within reach of young children, who may eat them as sweets with harmful results."85
The incidence of iron exposures continued to increase in the 1980s, ultimately becoming, in the 1990s, the leading cause of poisoning deaths reported to poison centers among children younger than 6 years. This problem was publicized as a result of a case series of tragic fatalities involving five toddlers in Los Angeles during a 6-month period in 1992, all of whom were exposed to prenatal vitamins containing iron.92 The association between death and prenatal vitamins highlights the availability of these potentially lethal medications in the homes of families with young children, ironically as a result of more attentive prescribing of prenatal iron. A case control study in Canada identified a fourfold increase in the risk of iron poisoning to the older sibling of a newborn during the first postpartum month.41 The authors concluded that almost half of all hospital admissions of young children for iron poisoning could be prevented by safer storage of iron supplements in the year before and the year after the birth of a sibling.
In 1997, the Food and Drug Administration (FDA) mandated that all iron salt-containing preparations have warning labels on them regarding the dangers of pediatric iron poisoning.23 In addition to the warning labels, the FDA launched an educational campaign to alert caregivers and prescribers of the potential toxicity of iron supplements.24 Other preventive initiatives instituted by the FDA in 1997 included unit dosing (blister packs) of prescriptions containing more than 30 mg of elemental iron and limitations on the number of pills dispensed (ie, ...