Iron CLINICAL PEARLS Iron toxicity begins with vomiting and progresses to metabolic acidosis and multisystem organ failure Serum iron levels contribute to evaluation, but not correspond well with severity of illness Treatment for patients with suspected serious iron toxicity begins with aggressive supportive care and early institution of deferoxamine Current Evidence In the 1990s, iron poisoning was one of the most common, potentially fatal intoxications in children Most serious childhood poisonings result from ingestion of maternal prenatal vitamins or ferrous sulfate tablets (which unfortunately often look much like candy) that were intended for adults A common scenario is that the patient is a toddler whose mother has just had a new baby; the increased demands on the mother’s attention and almost universal prescription of iron to pregnant women combine to set the stage for this ingestion In addition, numerous exposures result from ingestion of iron-fortified children’s vitamins, but these tend to be far less toxic Sufficient data to define a safe lower limit for toxic iron ingestions are not available As little as 20 mg/kg of elemental iron has caused GI toxicity, whereas ingestions of more than 40 mg/kg often produce moderate toxic effects with profound toxicity seen after doses of 60 mg/kg Of course, it is often impossible to know the exact number of tablets ingested As few as ten 300-mg FeSO4 tablets have been fatal to a young child Furthermore, the elemental iron content of whole bottles of chewable vitamins is usually about 1,200 mg Industry standards typically lead to the use of child resistant caps for vitamin bottles that contain more than 250 mg of elemental iron Unit dose (blister) packaging has been advised for pills with high iron content These measures have led to a dramatic reduction in deaths due to exploratory iron poisoning Iron toxicity results from direct caustic effect on the GI mucosa and the presence of free iron in the circulation Pathologic changes include hemorrhagic necrosis of stomach and intestinal mucosa and lesions in the liver that range from cloudy swelling to areas of complete necrosis Occasionally, pulmonary congestion and hemorrhage are noted Excess free iron is believed to act as a