All children who ingest iron tablets accidentally are at risk of severe, possibly fatal, poisoning. Death in the first stage of acute iron poisoning is due to hypovolaemic shock; in the third stage it is due to widespread cellular dysfunction as a result of mitochondrial disruption caused by intracellular iron. It appears that once a critical amount of iron has reached the mitochondria therapy has little effect and the outcome is poor. Rational therapy must be started without delay. The crucial aspect of early management is to remove as much iron as possible from the intestine before absorption and tissue uptake can occur. The aims of parenteral chelation therapy are to prevent iron in the extracellular fluid from entering the cells and to protect the mitochondria from iron already in the cells. An effective circulating blood volume must be maintained. Iron poisoning occurs predominantly in areas where iron is given routinely to mothers during pregnancy without sufficient regard for its potentially lethal effects on toddlers. Child-proof packaging is the single most effective way to prevent iron poisoning but it is expensive and not practical in poor countries. Iron prophylaxis in pregnancy should be routine only in areas where a high prevalence of iron deficiency justifies it. It should be accompanied by education of the public, pharmacists, nurses and doctors.