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INTRODUCTION

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Iron poisoning has become uncommon. This success may underscore the importance of interventions gleaned from poison control center data and poison prevention advocacy. Blister packaging and smaller iron dosages, as well as education of parents and health care professionals have led to a great decline in iron-related morbidity. However, when significant iron poisonings do occur, clinicians must be aware of the nuances of presentation and diagnosis and be prepared to intervene if gastrointestinal (GI) toxic effects, acid–base disturbances, altered mental status, or hemodynamic compromise arise.

HISTORY AND EPIDEMIOLOGY

Iron salts such as ferrous sulfate have been used therapeutically for thousands of years and continue to be available, both with and without a 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. In 1950, the manufacturer of “fersolate,” an iron supplement, 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.”78

The incidence of iron exposures continued to increase in the 1980s, becoming the leading cause of poisoning deaths reported to poison control centers among young children in the 1990s (Chap. 130). This problem was highlighted in a case series of five toddlers with unintentional fatal exposure to prenatal vitamins containing iron.11 The association between iron poisoning and prenatal vitamins highlights the availability of these potentially lethal medications in the homes of families with young children as an unintended consequence of more rigorous use of prenatal iron in pregnant women. 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.38 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 display warning labels regarding the dangers of pediatric iron poisoning. In addition to the warning labels, the FDA launched an educational campaign to alert caregivers and prescribers of the potential toxicity of iron supplements . The FDA also required unit dosing (blister packs) of prescriptions for preparations containing more than 30 mg of elemental iron and limitations on the number of pills dispensed. These efforts to prevent unintentional exposures dramatically decreased the incidence of poisoning and were pivotal in decreasing morbidity and mortality associated with iron poisoning.73 However, in 2003, the FDA rescinded the blister packaging requirement in response to a lawsuit by ...

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