(105) Iron Monitoring in Infants on Long-term TPN and Impact of IV Iron Supplementation on Transfusion Needs

Background: Preterm and critically ill neonates on chronic total parenteral nutrition (TPN) are at high risk for iron deficiency—due to missed placental transfer, frequent phlebotomy, rapid growth, and insufficient parenteral iron—which can cause anemia, impaired neurodevelopment, and poor growth. European guidelines and an international consensus recommend iron-status monitoring after ≥4 weeks of TPN, but no formal U.S. recommendations exist.

Objectives: To implement and evaluate a guideline for iron-status monitoring in infants on long-term TPN and assess whether intravenous (IV) iron supplementation reduces red blood cell (RBC) transfusions.

Design/Methods: We performed a single-center, retrospective cohort study in our neonatal ICU. Infants receiving ≥28 consecutive days of TPN were identified before (“Pre,” Jan–Dec 2022; n=39) and after (“Post,” Sep 2023–Sep 2024; n=42) guideline implementation. Eligible Post patients had iron, total iron binding capacity (TIBC), ferritin, and C-reactive protein (CRP) added to routine labs drawn 25–42 days after starting TPN. A pediatric hematologist reviewed labs, calculated iron deficits, and recommended IV iron dosing. We compared monitoring uptake, IV iron use, and transfusion outcomes between Pre vs Post, and within Post between treated vs untreated subgroups. Continuous variables were analyzed by t-test and paired t-test; categorical variables by χ²; p< 0.05 was significant.

Results: • Monitoring increased from 0% (0/39) to 79% (33/42) Post-implementation
• Of 33 Post patients with labs, 9 (27%) received IV iron sucrose (mean 1.7 ± 0.8 doses)
• Following supplementation, 7/9 (78%) treated infants required no further RBC transfusions; 2 received peri-operative transfusions only
• Mean transfusions after labs were lower in treated vs untreated Post infants (0.7 ± 1.0 vs 1.3 ± 1.4; p=0.18)
• Baseline lab values (iron, TIBC, ferritin, CRP) did not differ between subgroups (all p>0.65)
• Within treated infants, paired early vs late labs showed a nonsignificant rise in TIBC (252 ± 72 to 377 ± 25 µg/dL; p=0.17) and decrease in ferritin (361 ± 278 to 73 ± 45 ng/mL; p=0.11)

Conclusions: Implementing an iron-monitoring guideline increased lab surveillance to 79% of eligible infants. IV iron was administered to 27% of monitored infants, with a trend toward fewer transfusions and improved iron indices. A larger, prospective study is warranted to confirm whether targeted IV iron supplementation can significantly reduce RBC transfusions and improve growth and neurodevelopmental outcomes