AAP updates guidance on pediatric iron deficiency screening and treatment

Iron deficiency remains one of the most common nutritional deficiencies among children and adolescents in the United States, prompting the American Academy of Pediatrics (AAP) to issue updated recommendations on prevention, screening, diagnosis, and treatment. The new clinical report expands previous guidance by addressing care across infancy through adolescence and incorporates emerging evidence on laboratory evaluation, oral iron dosing, and the role of intravenous iron therapy.

The report replaces the AAP's 2010 recommendations for children younger than 3 years and broadens the focus to include older children and adolescents. It also emphasizes screening strategies tailored to age and risk factors, with the goal of identifying iron deficiency before progression to iron deficiency anemia (IDA).

When should pediatricians screen children for iron deficiency?

The updated guidance recommends universal screening for iron deficiency and IDA in all infants and young children between 9 and 18 months of age, with the timing determined by the child's primary source of nutrition during infancy.

Infants primarily receiving human milk should be screened between 9 and 12 months because of their increased risk of iron deficiency if they have not received adequate iron supplementation. Those primarily receiving iron-fortified formula should instead undergo screening between 15 and 18 months, when the transition to cow's milk or plant-based milk alternatives often results in substantially lower dietary iron intake.

The report also introduces universal laboratory screening for female adolescents at least 1 year after menarche but no later than age 14 years. The authors note that adolescents who menstruate have the highest prevalence of iron deficiency and IDA, largely because of menstrual blood loss, and that mild iron deficiency may progress to severe anemia requiring hospitalization if left unrecognized.

What laboratory tests are recommended?

Rather than relying solely on hemoglobin measurement, the report recommends screening with both a complete blood count (CBC) and serum ferritin whenever feasible. This approach allows clinicians to detect iron deficiency before anemia develops and begin treatment earlier.

The guidance also updates ferritin thresholds used to diagnose iron deficiency. Based on available evidence and recent hematology recommendations, the AAP now recommends defining iron deficiency as a serum ferritin level of 20 ng/mL or lower in infants, children, and school-aged children, and 30 ng/mL or lower in adolescents and all menstruating individuals. The authors caution that ferritin should be interpreted carefully in patients with acute or chronic inflammation because it functions as an acute-phase reactant and may appear falsely normal or elevated.

How should iron deficiency anemia be treated?

The report highlights a shift toward simpler oral iron regimens. For young children with IDA, the recommended initial treatment is ferrous sulfate at 3 mg/kg of elemental iron administered once daily rather than multiple divided doses. For most adolescents, one tablet of ferrous sulfate containing 65 mg of elemental iron taken once daily is considered sufficient when adherence and correction of the underlying cause are ensured.

The guidance notes that ferrous sulfate remains the preferred first-line therapy because of its effectiveness, widespread availability, and lower cost. Although iron polysaccharide formulations may have better palatability, evidence suggests ferrous sulfate produces greater improvements in hemoglobin among children with nutritional IDA. Oral iron is best taken on an empty stomach or with water, while dairy products, tea, and coffee should be avoided around dosing because they reduce iron absorption. Vitamin C supplementation is not routinely necessary.

Which children require additional evaluation or intravenous iron?

The report recommends reassessing patients approximately 1 month after initiating therapy using a CBC and reticulocyte count to confirm hematologic response. Treatment should generally continue for 3 months after normalization of hemoglobin to replenish iron stores, with repeat ferritin testing helping determine whether additional supplementation is needed.

Children with severe anemia, recurrent or persistent IDA, malabsorption syndromes, chronic inflammatory conditions, or inability to tolerate or absorb oral iron may require referral to a pediatric hematologist and consideration of intravenous iron therapy. The authors note that contemporary IV iron formulations have substantially improved safety profiles but should generally be administered in centers experienced with pediatric parenteral iron therapy.

The authors conclude that early identification and treatment remain essential because iron deficiency can affect neurologic development, cognition, behavior, and overall health throughout childhood. As they write, "Early identification and prompt treatment of ID and IDA with iron may mitigate its negative effects."

Reference

Powers JM, Heeney MM, Hord J, et al; American Academy of Pediatrics Section on Hematology-Oncology; AAP Committee on Nutrition; American Society of Pediatric Hematology-Oncology. Prevention, screening, diagnosis, and treatment of iron deficiency and iron deficiency anemia in infants, children, and adolescents: Clinical report. Pediatrics. 2026;158(1):e2026077414. doi:10.1542/peds.2026-077414