Updated AAP guidance changes iron deficiency screening and treatment in children

New guidance from the American Academy of Pediatrics (AAP) provides updated recommendations for the prevention, screening, diagnosis, and treatment of iron deficiency and iron deficiency anemia in infants, children, and adolescents. The clinical report addresses screening at different stages of childhood, laboratory evaluation, iron supplementation, treatment response, and populations at increased risk for deficiency.

To discuss how pediatricians can apply the recommendations in clinical practice, Contemporary Pediatrics spoke with Melissa Wallach, MD, FAAP, a pediatrician at Hackensack Meridian K. Hovnanian Children’s Hospital at Jersey Shore University Medical Center in Neptune, New Jersey. Wallach discussed changes in screening and supplementation, risk factors that may warrant additional testing, considerations for breastfed infants and menstruating adolescents, and approaches to treatment and follow-up.

Contemporary Pediatrics: What are the most important changes or updates in the new AAP guidance on iron deficiency, and what should pediatricians be doing differently in practice as a result?

Melissa Wallach, MD, FAAP: The most important changes in the new AAP guidance on iron deficiency include the timing for screening for both exclusively breastfed infants and infants who consume formula, adding ferritin to the CBC for diagnosis, and when to start iron supplementation.

For menstruating adolescents, it is advised to screen with a CBC and ferritin at least 1 year postmenarche or by age 14 years. Breastfed infants should be screened at 9 to 12 months of age, whereas formula-fed infants should be screened at 15 to 18 months of age once transitioned to cow’s milk or plant-based milk. Children with risk factors, such as excessive milk intake, should be screened at annual well visits until age 4 years.

It should be noted that ferritin is an acute-phase reactant and therefore can be elevated in a patient who is anemic but also has an acute or chronic inflammatory condition.

Contemporary Pediatrics: Which infants and children are at greatest risk for iron deficiency, and are there particular risk factors or clinical signs that should prompt screening beyond routine recommendations?

Wallach: The following populations and risk factors should warrant screening beyond universal recommendations:

• Premature infants born before 37 weeks because they miss out on third-trimester iron accrual
• Infants exclusively breastfed beyond age 6 months who are not receiving iron supplementation
• Toddlers transitioning from formula to cow’s milk or plant-based milk, especially if they drink more than 24 oz per day
• Children who start cow’s milk before 1 year of age and those who do not eat enough iron-rich foods
• Menstruating adolescents because of rapid growth and menstrual blood loss, especially those with heavy or dysfunctional uterine bleeding
• Children with obesity because of decreased iron absorption and larger body mass with greater iron demands
• Children with blood loss from the gastrointestinal tract or epistaxis
• Children with inflammatory bowel disease or celiac disease
• Children with rheumatologic disorders or chronic kidney disease
• Blood donors
• Endurance athletes
• Children and adolescents following strict vegetarian or vegan diets that lack heme iron and do not include enough nonheme iron
• Children with genetic causes, such as iron-refractory iron deficiency anemia
• Children with nutritional deficiencies related to social factors, such as food insecurity
• Populations in which iron deficiency is more prevalent, including Alaska Native children, Latino toddlers and adolescents, and African American adolescents

Clinical signs concerning for iron deficiency include fatigue, shortness of breath, headaches, dizziness, and pica. Younger children may present with increased fussiness and adolescents with dizziness. Pica may present as eating dirt, rocks, and paper in younger children and as eating ice and starchy nonfood items in adolescents.

Contemporary Pediatrics: For exclusively breastfed infants, what should pediatricians discuss with families about the timing and dosing of iron supplementation, and what barriers to adherence commonly arise?

Wallach: Exclusively breastfed infants should be started on iron supplementation at 1 mg/kg/day of elemental iron by 4 months of age, or 6 months of age for those who want to wait until foods that contain iron are administered.

Barriers to adherence can include adverse effects of iron supplements, such as constipation and abdominal pain, unfavorable taste, and remembering to administer it every day. Cost and access to health care can be other barriers. Iron can discolor teeth and darken stool, which can worry caregivers. Iron is best given on an empty stomach and not concomitantly with dairy products, which can make timing of administration a challenge.

Contemporary Pediatrics: Adolescence introduces additional risk factors, particularly heavy menstrual bleeding. How should pediatricians screen adolescents for iron deficiency, and when should heavy menstrual bleeding prompt further evaluation or referral?

Wallach: For menstruating adolescents, it is advised to screen with a CBC and ferritin at least 1 year postmenarche or by age 14 years. Adolescents with heavy menstrual bleeding and/or abnormal uterine bleeding should be screened annually at their well visits.

Adolescents who do not respond after 1 month of treatment can be evaluated for other diagnoses. It is also important to check the dosing of iron and make sure there are no barriers to taking the iron. If still anemic after 3 months of treatment, or if 1 or more episodes of anemia occur in a 2-year period following resolution, further workup is needed.

If an adolescent has excessive bleeding, the cause should be evaluated by the pediatrician, pediatric gynecology, or adolescent medicine and should include an evaluation for a bleeding disorder such as von Willebrand disease.

Other indications for specialist referral across age groups include referral to gastroenterology if inflammatory bowel disease, celiac disease, or gastrointestinal bleeding is suspected. A hematology referral is needed if the patient has another cause of microcytic anemia, such as sideroblastic anemia or thalassemia.

Contemporary Pediatrics: Once iron deficiency is identified, what does the updated guidance recommend regarding oral iron treatment, monitoring, and follow-up, and how can pediatricians determine whether a child is responding adequately to therapy?

Wallach: Once iron deficiency is diagnosed with a serum ferritin below 20 ng/mL for young and school-aged children, it is recommended to supplement with 3 mg/kg daily of elemental iron, usually with ferrous sulfate. For adolescents with a serum ferritin below 30 ng/mL, treat with 65 mg of elemental iron daily.

If the hemoglobin is less than or equal to 7 g/dL and the patient is clinically stable, they can be treated with oral iron and close outpatient follow-up. If they are not clinically stable, they need a blood transfusion given slowly in smaller aliquots. If the child does not respond to oral iron therapy, IV iron can be given. Specialty referral is needed to administer parenteral iron. Follow-ups should be scheduled at 1 and 3 months after starting supplementation.

For mild anemia, defined as a hemoglobin greater than or equal to 9 g/dL, normalization of the hemoglobin is expected at 1 month. For severe anemia, with a hemoglobin below 9 g/dL, it is expected to increase by 2 g/dL after 1 month of supplementation. Treatment duration is advised for 3 months.

Checking the ferritin level is how the pediatrician can determine whether the child is responding adequately to iron supplementation. If the ferritin remains below 20 ng/mL, extend supplementation by another 3 months. Preterm infants should be started on iron supplementation by 2 weeks of age at a dose of 2 to 3 mg/kg/day.

Reasons why oral iron therapy may not work include ongoing blood loss, malabsorption, and chronic inflammatory conditions that increase the production of hepcidin.

Reference

Powers JM, Heeney MM, Hord J, et al; AAP 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). doi:10.1542/peds.2026-077414