14 April 2025
Updated dosing of oral iron for iron-deficiency anaemia in children
Following guidance published in 2021 by the British Society of Gastroenterology on the treatment of iron-deficiency anaemia in adults, BNF recommendations for oral iron salts in adult patients were updated to recommend lower doses of oral iron than those which have been traditionally used for the treatment of iron-deficiency anaemia. Following on from this, we noted that adult dosing was now lower than paediatric dosing, and so we undertook a review of oral iron dosing in BNF for Children.
Lower treatment doses (e.g. 1 tablet once daily or on alternate days) and a simpler treatment regimen are as effective, have fewer side effects, and increase compliance. Absorption following lower dosing has been reported to be at least as effective as traditional dosing (e.g. 1 tablet two or three times daily); hepcidin, the hormone that regulates iron homeostasis, is minimized with lower dosing leading to increased iron absorption. Whereas with traditional treatment doses, the high concentration of iron stimulates hepcidin production, leading to reduced absorption of subsequent iron doses through the gut mucosa. Our review found that this rationale could be extended to children.
Our editorial team appraised primary literature as well as UK and international guidelines, and specialist trust protocols. A high-quality UK source supported use of adult dosing for children aged 12–17 years, but evidence for younger children was limited. We therefore consulted with experts from the British Society of Paediatric Gastroenterology, Hepatology and Nutrition, and the Royal College of Paediatrics and Child Health. Expert advice and primary literature guided the development of a new dosing regimen for neonates and children aged under 12 years.
This new approach to dosing includes a reduced frequency of oral iron, which therefore allows dosing for treatment and prophylaxis of iron-deficiency anaemia to be aligned. For liquid formulations, age-banded doses were added to remove the need for weight-based dose calculations, and doses were rounded for ease of administration. Additionally, a specific indication for prophylaxis of iron-deficiency anaemia in pre-term or low birth-weight babies was added for all oral iron salts. Updates were also made to advice for monitoring treatment, and the Anaemia, iron-deficiency treatment summary.
The new dosing regimen is unique to the BNF for Children and has been ratified by the Paediatric Formulary Committee. It has also been made available for open peer review in late 2024, with the feedback received showing support for the changes.
Updates to BNF for Children were published for the April 2025 update for online and app versions, and will be included in the next print edition: BNF for Children 2025-2026. See the Anaemia, iron deficiency treatment summary, and indications and dose, monitoring, and patient and carer advice sections in individual drug monographs: ferrous fumarate, ferrous gluconate, ferrous sulfate, and sodium feredetate.
