Iron is among the most common toxic exposures in children
Accidental ingestion in children < 6 years predominates
Colorful tablets visually similar to candy
Intentional overdose demographics
Adolescent females represent 91% of intentional cases in 13-20 age group
One-third of intentional overdoses involve concurrent alcohol use
Household risk factors
Prenatal vitamins in households with pregnant women
Adult iron supplements for anemia treatment
Iron-containing children's multivitamins
Mortality data
Fulminant hepatic failure from iron toxicity carries high mortality
Early chelation and decontamination reduces mortality significantly
Liver transplantation required in severe cases
Pathophysiology
Mechanisms of iron toxicity
Free radical generation
Iron catalyzes Fenton reaction producing hydroxyl radicals
Lipid peroxidation damages cellular membranes
Mitochondrial dysfunction from direct iron toxicity
GI mucosal injury
Direct corrosive effect on gastric and intestinal mucosa
Hemorrhagic gastroenteritis and mucosal necrosis
Late stricture formation from scarring at 2-8 weeks
Cardiovascular toxicity
Free iron directly impairs myocardial contractility
Vasodilation from iron-mediated nitric oxide generation
Distributive and cardiogenic shock combined picture
Hepatotoxicity mechanism
Iron accumulates in hepatocytes via portal circulation
Oxidative stress causes hepatocellular necrosis
Fulminant hepatic failure with coagulopathy and encephalopathy
Five-phase clinical course
Phase 1 (0.5-6 hours): GI toxicity from mucosal injury
Phase 2 (6-24 hours): relative stability as GI absorption plateaus
Phase 3 (12-48 hours): systemic toxicity with shock and acidosis
Phase 4 (2-4 days): hepatotoxicity with coagulopathy
Phase 5 (2-8 weeks): GI scarring and stricture formation
Therapeutic Considerations
Chelation principles
Deferoxamine mechanism
Forms ferrioxamine complex with free circulating iron
Ferrioxamine renally excreted producing vin rose urine
Does not chelate iron bound to hemoglobin or transferrin
Chelation timing
Earlier chelation improves outcomes
Begin as soon as indications met regardless of serum iron result pending
Do not delay for confirmatory lab if clinical picture severe
TIBC limitations
Total iron-binding capacity unreliable in acute overdose
Rises artifactually; do not calculate free iron from TIBC
Serum iron level alone guides management
Decontamination rationale
Whole bowel irrigation evidence
Polyethylene glycol reduces tablet transit time
Clears iron before further absorption occurs
Most effective when tablets visible on KUB
Activated charcoal exclusion
Iron does not adsorb to activated charcoal
Giving charcoal wastes time and obscures endoscopy field
Hepatic failure management
N-acetylcysteine empirical use
Antioxidant mechanism may provide hepatoprotection
Limited specific evidence in iron toxicity
Generally considered safe adjunct
Transplant threshold
King's College criteria for non-acetaminophen liver failure
Early transplant center transfer for rising INR and encephalopathy
Patient Discharge Instructions
copy discharge instructions
Iron poisoning home care instructions
Medications and follow-up
All follow-up appointments must be kept
Psychiatric follow-up if this was intentional
Liver function blood tests may be needed in 48-72 hours
Activity and diet
Normal diet once nausea has resolved
Avoid alcohol for at least 1 week
Rest as needed
Warning signs requiring immediate return to ER
Vomiting returning after seeming to recover
Iron poisoning has a deceptive phase where you feel better before getting worse
Return immediately if symptoms return 6-24 hours after ingestion
Bloody vomit or black tarry stools
Severe abdominal pain
Confusion, extreme drowsiness, or difficulty staying awake
Feeling faint or losing consciousness
Yellowing of skin or eyes appearing days after exposure
Vomiting that prevents eating and drinking for more than a few hours
Prevention for families
Store ALL iron-containing supplements locked away from children
Prenatal vitamins are particularly dangerous to young children
Adult iron supplements must be in childproof containers stored high
Never leave iron tablets where children can access them
Call poison control immediately if a child ingests iron: 1-800-222-1222
Late complication awareness
Pyloric or bowel narrowing can occur 2-8 weeks after significant ingestion
Return if persistent vomiting or inability to eat develops weeks later
This represents scarring from the injury to the stomach lining
References
Guidelines and key sources
Toxicology guidelines and references
Tenenbein M. Toxicokinetics and Toxicodynamics of Iron Poisoning. Toxicology Letters 1998; PMID 10022330
Bateman DN et al. Iron Overdose Epidemiology, Clinical Features and Iron Concentration-Effect Relationships: The UK Experience 2008-2017. Clinical Toxicology 2018; PMID 29587543
Chyka PA, Butler AY. Assessment of Acute Iron Poisoning by Laboratory and Clinical Observations. American Journal of Emergency Medicine 1993; PMID 8476468
Chyka PA, Butler AY, Holley JE. Serum Iron Concentrations and Symptoms of Acute Iron Poisoning in Children. Pharmacotherapy 1996; PMID 8947978
Vega IL, Griswold MK, Laskey D. Acute Medication Poisoning. American Family Physician 2024; PMID 38393798
Additional key references
Robertson A, Tenenbein M. Hepatotoxicity in Acute Iron Poisoning. Human and Experimental Toxicology 2005; PMID 16323571
Burkhart KK et al. The Rise in the Total Iron-Binding Capacity After Iron Overdose. Annals of Emergency Medicine 1991; PMID 2024794
Yu D, Giffen MA. Suicidal Iron Overdose: A Case Report and Review of Literature. Journal of Forensic Sciences 2021; PMID 33729557
Kasuda K et al. Liver Transplantation for Acute Liver Failure After Intentional Iron Overdose. Pediatric Transplantation 2025; PMID 41039699
Crofton AK et al. Unintentional Paediatric Iron Poisoning: A Retrospective Case Series. Emergency Medicine Australasia 2021; PMID 34121325
Halil H et al. Minimum Ingested Iron Cut-Off Triggering Serious Iron Toxicity in Children. Pediatrics International 2019; PMID 30882955
Coding standards
ICD-10 T45.4X1A: poisoning by iron and its compounds, accidental
ICD-10 T45.4X2A: poisoning by iron and its compounds, intentional self-harm
SNOMED CT concept: iron poisoning (disorder)
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.