Dose:   1 mg/kg/Day IV or IM

Frequency: Q Day            

Comments: Iron dextran is a complex of ferric hydrochloride and dextran for IM or IV use. Friel (J Parenteral and Enteral Nutrition 1995; 19:114) studied the effectiveness of IV iron supplementation to low birth weight infants using a dose of 200 to 250 mcg/kg/day. The study suggested that newborns require 1000 mcg/kg/day and that iron contained in red blood cells from transfusions does not provide an adequate supply of iron. Studies from the 1960s showed that doses of parenteral iron (100 to 250 mg/kg IM) prevented iron deficiency anemia. Case reports of IV administration of iron have not been associated with the adverse effects noted in adults. Doses in these studies have been generally low. James (Aust Paediatr 1979; 15:67) suggests using a dose of 704 mcg/kg/day. Meyer (J Pediatr 1996; 129:258) compared intravenously administered iron (6 mg/kg/week) with orally administered iron (12 mg/kg/day) to infants receiving erythropoietin (600 units/kg/week). Both resulted in supplying sufficient iron for erythropoiesis in stable infants. There were no problems reported from the intravenous administration of iron. Weight accretion was greater in the intravenously supplemented group. The orally administered group had falling serum ferritin levels while those in the IV group were stable. For iron deficient patients, an estimate of the IV iron replacement can be made using the following equation:

The calculated amount of iron dextran can be infused in TPN. The total amount is divided by 3 and infused daily for 3 days with a maximum daily dose of 25 mg. It may also be mixed in at least 10 ml of NS and infused over at least one hour (see preparation below).

Toxicity: Both lactoferrin and transferrin have bacteriostatic properties when they are not saturated with iron. Although in vitro and animal data suggest that iron fortified formulas and oral iron might predispose to infections, epidemiological support for this hypothesis remains scant. Finally, excessive iron administration may lead to a deficiency of vitamin E. (Dallman, "Nutritional Anemia of Infancy", Nutrition during Infancy (edited by Tsang and Nichols) Hanley & Belfus, Inc: Philadelphia, page 224, 1988. Kumpf (Nutrition Clin Pract 1996; 11:139) reports on a number of adverse effects associated with parenteral iron administration in adults. Reactions occurred in 26%, but were of significance in only 5%, and life-threatening in only 0.6% of the adults. Local reactions are more common after IM administration including pain, sterile abscesses, brown-staining of skin, and necrosis. Phlebitis may occur after IV administration. Hypersensitivity reactions include urticaria and febrile episodes. Anaphylaxis is characterized by sudden onset of CV collapse. Using a dilute solution for infusions in infants effectively prevents this. Delayed reactions occur 24 to 48 hours after IV or IM administration. These include lymphadenopathy, arthralgia, fever, headache, nausea, and vomiting.

Preparation: Iron dextran is available from manufacturer in 2 ml vial (50 mg/ml). Meyer (J Pediatr) diluted the amount in 10 ml of normal saline and infused over 1 hour. Friel (J Parenteral Enteral Nutr) added the iron to a TPN solution. Observe carefully for the first hour of infusion. Check vital signs with BP every 15 minutes (X 4) after initial dose of IV iron. If changes in vital signs or rash occurs, discontinue infusion and notify MD or NNP.

Compatibility: Compatible with TPN, however iron dextran may be adsorbed to sterilizing filters (will stain reddish-brown) resulting in significant loss particularly when small amounts are administered. It is also stable in normal saline.