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Iron Poisoning

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Iron Poisoning ,11 Iron Poisoning Jeffrey S. Fine, MD D ron poisoning has always been of particular Iron is a group-VIII transition metal, with electrons interest to pediatricians: children are frequently distributed throughout five 3d orbitals. When iron forms exposed to iron-containing products, and they chemical compounds or complexes with large proteins experience the worst toxicity. The first well-described such as hemoglobin, these electrons shift between cases of iron poisoning were published in the 1940s higher and lower energy orbitals and achieve different and 1950s, the classic animal experiments were per- spin states. 2,4 With this variable electron distribution, formed in the 1950s and 1960s, and the use of the iron can exist in oxidation states between -2 and +6, chelator deferoxamine as an antidote for iron poison- either donate or receive electrons, and achieve variable ing was introduced in the 1960s. redox potentials during electrochemical reactions. Most of what we know about the clinical presentation, This makes iron an ideal mediator of diverse biologi- the pathology, and the pathophysiology of iron poison- cal redox reactions such as when electrons are trans- ing comes from this early work although research con- ferred down the mitochondrial cytochrome chain. tinues. What has changed most over the past 50 years is Table 1 lists some basic facts about the physical chem- the approach to management. As with many types of istry and biochemistry of iron. poisoning, there is now an emphasis on excellent sup- Physiologically, iron exists primarily in 2 stable oxi- portive care with an individualized approach to gastroin- dation states: ferrous iron (Fe +2 or Fe [II]) and ferric testinal decontamination and a selective use of antidotes. iron (Fe +3 or Fe [III]). In aqueous solution Fe +2 is oxi- With this strategy, the deaths related to iron poisoning dized to Fe +3, which often forms insoluble complexes have been reduced to only a small number each year. This at physiologic pH. Iron chelators such as transferrin or article reviews the epidemiologic, clinical, animal, and deferoxamine form soluble complexes with Fe +3. laboratory science related to iron poisoning and its man- A typical American diet contains approximately 15 agement and focuses on several areas of controversy. to 40 mg of iron per day most of which is in the ferric form, which is insoluble at physiologic pH and poorly absorbed. This Fe +3 is released from food proteins and Background reduced to the ferrous form by gastric acid. Iron is the fourth most abundant atomic element in Absorption of dietary iron takes place primarily in the the earth's crust and is found in the minerals hematite, duodenum and upper jejunum and is regulated accord- magnetite, and siderite.~ Biologically, iron is an essen- ing to the state of the body's iron stores. Heme iron is tial nutrient for most living organisms because it is a absorbed better than nonheme iron, and different food component or cofactor of many critical proteins and components may affect iron absorption. For instance, enzymes such as hemoglobin, myoglobin, catalase, ascorbate increases and phytates decrease absorption; xanthine oxidase, aconitase, reduced nicotinamide however the overall effect of food is to decrease iron adenine dinucleotide, ribonucleotide reductase, perox- absorption. The body efficiently recycles iron released idases, and cytochrome oxidase. 2,3 from senescent red blood cells, so the daily require- ment for iron is approximately 1 mg to cover losses of iron in stool, sweat, and urine. Menses accounts for an Jeffrey S. Fine, MD, is Assistant Director of Pediatric Emergency additional need of 1 mg/d for women. Thus approxi- Services at Bellevue Hospital and an assistant professor of Pediatrics mately 10% of dietary iron is absorbed. 1-3 at New York University School of Medicine, New York, New York. The intestinal mucosal cell has few barriers to iron Curr Probl Pediatr 2000;30:71-90. Copyright © 2000 by Mosby, inc. uptake, but once inside the cell the transfer of iron to 0045-9380/2000/$12.00 + .15 53/1,/104055 the plasma is highly regulated. The physiology of iron doi:10.1067/mps.2000.104055 absorption and metabolism is quite complex and out- Curr Probl Pediatr, March 2000 71 TABLE 1. Iron facts Epidemiology of Iron Poisoning Atomic no.: 26 The American Association of Poison Control Centers Atomic weight: 55.85 (AAPCC) is a consortium of 66 regional poison control Density: 7.784 g/cm 3 and information centers located throughout the United Normal serum level: 80-180 pg/dL (1¢32 #mol/L) States. Each year the AAPCC collects standardized epi- Ferrous = Fe+2 or Fe (11) demiologic data about poisonings reported to these cen- Ferric = Fe+3 or Fe (111) ters, and this information is published annually. For Required daily dose: I mg/kg per day (maximum 15 mg) 1997, the AAPCC reported 1.5 million poisoning expo- sures for children and adolescents younger than 20 years. 9 These pediatric exposures accounted for 67% of side the scope of our discussion; the reader is referred all the reported poisoning exposures. Children younger to several recent reviews for more information. 1&5 A than 6 years accounted for 77% of the pediatric expo- typical adult has approximately 3 to 4 g of iron (30-40 sures and 50% of all reported exposures. mg/kg body weight); most of this iron is found in In 1997, there were 26,544 AAPCC-reported expo- hemoglobin or stored as ferritin. Only 3.5 mg (0.1%) sures for all types of iron-containing compounds by circulates in the plasma. 2 children and adolescents accounting for 1.7% of all Iron toxicity is related to the generation of free rad- reported pediatric poisoning exposures; 87% were in icals. 6,7 Both normal and pathologic cellular process- children younger than 6 years. Sixty-two percent of es produce superoxide (02-) and hydrogen peroxide these childhood exposures were to pediatric multivita- (H202) byproducts, whereas enzymes such as super- min tablets, which rarely lead to serious toxicity after oxide dismutase, glutathione peroxidase, and catalase ingestion. Thirty percent of these exposures were to normally metabolize and neutralize these free radicals. adult preparations such as iron pills or prenatal vita- One of the effects of 02 - is the release of stored iron mins with iron, which are responsible for almost all of from ferritin. The free iron reacts with O 2- and H202 the serious toxicity related to iron poisoning. to produce other more reactive and toxic-free radicals Iron-containing products are available in many house- such as the hydroxyl radical: 6,7 holds with young children. Iron pills are prescribed for most pregnant women, and many children are receiving 02- + Fe +3 --~ 02 + Fe +2 multivitamins with iron. Many of the prenatal vitamins are brightly colored, sugar coated, and resemble popu- Fe +2 + H202 --~ Fe +3 + HOo + OH- lar candies, such as M&M's or Good & Plenty (Fig 1). 1° Many children's multivitamins are associated with car- O2o- + H202 --~ O 2 + HOo + OH- toon characters like the Flintstones. In this regard, the The hydroxyl radical (HOo) formed through this comments of Spencer, u written in 1954, seem timely: reaction can depolymerize polysaccharides, cause Now it seems irrational that some things which children are DNA strand breaks, inactivate enzymes, and initiate expected to take, such as cod liver oil, remain unpalatable, lipid peroxidation, which is a self-amplifying process whereas ferrous sulphate tablets, which are intended main- that is particularly damaging to cellular and subcellular ly for adult use, are made both attractive and sweet. membranes. 6,7 For example, when lysosomal mem- The reasons that children ingest drugs are multifactor- branes are destroyed, proteolytic enzymes are released ial and include developmental level, inadequate parental inside the cell, causing further cell damage. If the dam- knowledge about the toxic potential of individual agents age is irreparable, it can also lead to cell death. 8 such as iron, access to medications, imitative behavior, The body protects itself from the toxicity of free iron lack of supervision, and intrafamilial conflict.12,13 by keeping it chelated during almost all phases of Almost all deaths from iron poisoning are in children absorption and distribution. From the enterocyte, iron is younger than 3 years and follow large exposures to adult accepted for transport through the plasma by transferrin, iron preparations (30-40 pills), although death after the a [31-glycoprotein with 2 high-affinity binding sites for ingestion of as few as 5 pills has been reported. 14,15 Fe+3. One third of the body's iron is stored as ferritin, a Early series reported mortality rates of 50% from iron macromolecule capable of binding up to 4500 iron poisoning, which undoubtedly reflected a reporting bias atoms. Sixty percent of this ferritin is in hepatocytes, and for very sick, hospitalized patients. 16 Despite the extra- 40% is in myocytes and reticuloendothelial cells. ordinary number of exposures to iron-containing prod- 72 Curr Probl Pediatr, March 2000 ucts, deaths rarely occur. For the past 10 years, there has been an average of only 3 to 4 deaths per year reported by the AAPCC, although there are sporadic increases; in 1992, 11 childhood deaths were reported.14,17 This num- ber of reported deaths may be an underestimation of the actual incidence, because some deaths are not reported to regional poison control centers. 18 Although mortality statistics are relatively well maintained, data about poisoning morbidity are diffi- cult to ascertain. The AAPCC reports a significant amount of epidemiologic information related to poi- soning, but the annual reports do not stratify all the data according to age.
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