Navigating treatment dilemmas in severe paediatric IDA: A case report.

Iron deficiency anemia (IDA) is a leading cause of anemia worldwide, often managed with oral iron. Severe paediatric cases, however, raise uncertainty about when to use packed red blood cell (pRBC) transfusion versus intravenous (IV) iron. We report a 16-year-old male with autism spectrum disorder and severe nutritional IDA (hemoglobin 31 g/L) who presented with tachycardia and hypotension but no acute decompensation. Although transfusion was discussed, the patient declined, and he was managed with IV iron followed by oral supplementation. Hemoglobin recovery was brisk, rising by 13 g/L within 5 days, but functional recovery was slow, taking 6 months. This case highlights the therapeutic dilemma in adolescents with chronic severe IDA who may meet criteria for transfusion yet remain clinically stable. IV iron offers a viable alternative in this setting, but paediatric guidelines are needed to better define transfusion thresholds and the role of IV iron.