Toddler Deaths Resulting from Ingestion of Iron Supplements -- Los Angeles, 1992-1993

During June 1992-January 1993, five children aged 11-18 months in the Los Angeles area died after ingesting iron supplement tablets. The first death was reported by the Consumer Product Safety Commission (CPSC) to the Los Angeles County Department of Health Services (LADHS) in November 1992 and then reviewed by the Los Angeles County Child Death Review Committee. On January 6, the Los Angeles County coroner's office reported three additional deaths associated with ingestion of iron to the Child Death Review Committee and the health department. A fifth death resulting from iron poisoning was reported January 29. This report summarizes preliminary information from an investigation of these cases. Case 1. A 16-month-old boy died in June 1992 after ingesting 30-35 prenatal iron tablets that had been in a loosely capped container on a table. Prenatal 325 mg ferrous sulfate tablets, with an elemental iron content of 60 mg per tablet, were identified as the toxic agent. Medical treatment was delayed because clinical manifestations were not present initially. Case 2. An 18-month-old boy died in September 1992 after consuming an estimated 30-40 prenatal iron tablets. Prenatal 325 mg ferrous sulfate tablets, with an elemental iron content of 60 mg per tablet, were identified as the toxic agent. The tablets were in an uncapped bottle on a table. Case 3. A 12-month-old boy died in November 1992 after consuming an estimated 30 iron tablets. No container was available for confirmation of the strength of the dosage. Case 4. An 11-month-old girl died in December 1992. A 2-year-old sibling had fed the younger child 30-35 prenatal iron tablets. Prenatal 325 mg ferrous sulfate tablets, with an elemental iron content of 60 mg per tablet, were identified as the toxic agent. The iron tablets were in a box on the floor. Case 5. A 13-month-old girl died in January 1993 after consuming an unknown number of prenatal iron tablets prescribed for an older sister. Prenatal 325 mg ferrous sulfate tablets, with an elemental iron content of 60 mg per tablet, were identified as the toxic agent. The tablets were spilled on the floor for an unspecified period of time before the child was observed to have them in her mouth.

The prenatal iron supplements ingested in these five cases were red or green disk-shaped tablets with a glossy sugar coating; they are commonly used as an iron supplement for prenatal patients. All of the recovered containers had child-resistant safety caps and a warning that specified the need to keep all medications away from children.

On January 20, the LADHS issued a warning through the local media to parents and medical practitioners regarding the potential dangers of iron overdose.

Reported by: B Weiss, MPH, Injury Prevention and Control Project, E Alkon, MD, Public Health Programs, Los Angeles County Dept of Health Svcs; F Weindlar, Univ of Southern California Poison Control Center; A Kelter, MD, Emergency Preparedness and Injury Control Br, P Delacruz, Food and Drug Br, California Dept of Health Svcs. Health Studies Br, Div of Environmental Hazards and Health Effects, National Center for Environmental Health, CDC.

Editorial Note

Editorial Note: Iron is the most common cause of pediatric poisoning deaths reported to poison control centers in the United States (1). During 1991, 5144 ingestions of iron supplements were reported to poison control centers in the United States; 11 were fatal. Children aged less than 6 years accounted for 3578 (69.6%) ingestions of iron and nine of the deaths. In addition, 18,457 ingestions of iron in the form of multivitamin or combination preparations were reported; 16,021 (87%) occurred among children aged less than 6 years (1). During 1991, consumption of multivitamin preparations in the form of prenatal vitamins with iron caused two additional deaths among children aged 17 and 18 months (1).

Although a toxic dose of elemental iron is 30 mg/kg, and a fatal dose is typically more than 250 mg/kg, ingestion of doses as low as 60 mg/kg have resulted in death (2). More than 120 different iron-containing preparations are available by prescription and over-the-counter purchase (3). The children in this report each consumed approximately 30 tablets of iron supplements; the number of tablets associated with a toxic dose varies, depending on the form and amount of iron used. Although in three cases the iron supplement was a prescription item, the 60 mg per tablet dosage is also available in over-the-counter preparations. Ingestion of as few as five or six tablets of a high-potency preparation could be fatal for a 10-kg (22-lb) child.

Iron poisoning is characterized by four clinical stages (2). The first stage -- with a duration of up to 6 hours after ingestion -- is characterized by acute onset of gastrointestinal symptoms (i.e., vomiting and diarrhea) that may progress to shock, coma, seizures, and death. During stage two -- from 6 to 24 hours after ingestion -- patients may be asymptomatic; however, evaluation and treatment for iron poisoning should not be delayed. During stage three -- from 12 to 48 hours after ingestion -- there may be hepatic and renal failure and cardiovascular collapse. Stage four -- from 3 to 4 weeks after ingestion -- may include gastrointestinal obstruction and hepatic cirrhosis.

From 1982 through 1992, three children died from iron toxicity in Los Angeles County: one each in 1986, 1988, and 1990. Thus, the five deaths in 7 months reported here represent a substantial increase in iron-related deaths. Measures to prevent toxic ingestions (e.g., child-resistant packages and warning labels) were present in at least four cases described in this report. However, iron supplements may be sold over the counter, and public perception of the potential danger of a vitamin or mineral supplement product may be low. County and state health officials are investigating the morbidity and mortality associated with these supplements; CPSC is also assisting the LADHS in the investigation of this problem.

The following measures may help prevent iron toxicity-associated deaths: 1) iron supplements should be prescribed in limited amounts and dosages and when medically indicated; 2) health-care providers and others who prescribe or dispense iron supplements should emphasize to parents the hazards of unintentional iron consumption by children; and 3) adults should be instructed in the proper use of child-resistant packages when they receive them. Other considerations include the need to re-evaluate the effectiveness of child-resistant packaging and warning labels; for example, because ingestion of a small number of iron tablets may cause toxicity, tablets packaged in child-resistant individual blister packs may limit the number of tablets a child can access. Iron tablets should be made less appealing to children by eliminating use of sugar coating or attractive colors. Finally, educational efforts should be aimed at persons who use iron supplements and who have young children at home.

References

1. Litovitz TL, Holm KC, Bailey KM, Schmitz BF. 1991 Annual report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med 1992:10;452-505.

2. Baker MD. Iron. In: Noji EK, Kelen GD, eds. Manual of toxicologic emergencies. Chicago: Year Book Medical Publishers, 1989:496-506.

3. Physician's desk reference. 46th ed. Montvale, New Jersey: Medical Economics Company Inc, 1992.

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