New recommendations from the American Academy of Pediatrics (AAP) aim to help clinicians identify iron deficiency in children before progression to clinically significant anemia.

“The focus on iron deficiency rather than iron deficiency anemia is practice changing,” said Anne Vangarsse, MD, medical director of Valley Children’s Primary Care Group in Madera, California, who was not involved in the guidelines. “Iron deficiency can affect a child’s developing brain before anemia is apparent, and some developmental consequences may persist even after treatment if the deficiency is prolonged.”

Published in Pediatrics, the clinical report replaces the organization’s 2010 guidance, revising ferritin thresholds for diagnosis and recommending universal screening for menstruating teens. The recommendations were developed in collaboration with the American Society of Pediatric Hematology-Oncology. The AAP recommends screening not only infants and young children for iron deficiency and associated anemia but now also includes “adolescents, while also providing detailed guidance on treatment ranging from mild-to-severe cases,” said Satiro De Oliveira, MD, associate professor of pediatrics at UCLA Health in Los Angeles, who was not involved in writing the guidelines.

Iron deficiency remains common in the US, affecting approximately 15% of toddlers and 11% of female adolescents. A recent analysis using a ferritin cutoff of < 25 μg/L estimated that nearly 40% of adolescent girls had iron deficiency and around 6% had iron deficiency anemia. In children aged 1-5 years, 1%-2% of children may have iron deficiency anemia.

AAP previously recommended screening children for iron deficiency and iron deficiency anemia at 12 months old and in the presence of risk factors at any age. The new guidance calls for a more targeted approach: Infants receiving human milk as their primary source of nutrition should be screened between age 9 and 12 months, while those who are formula-fed should receive the screening at 15-18 months. Children should continue to be assessed for risk factors for the condition, which include excessive milk intake, inadequate dietary iron, obesity, and food insecurity, through age 4.

Earlier guidance focused only on young children up to 3 years old. AAP now recommends universal screening for iron deficiency in adolescents at least 1 year after they have started menstruation, bu t no l ater than 14 years old.

“In my experience, iron deficiency in female adolescents has been underrecognized and often only diagnosed once it progresses to moderate or severe anemia,” De Oliveira said. “Universal screening will be fundamental to address this issue.”

Iron deficiency can have consequences even in the absence of anemia because it is associated with adverse neurodevelopmental outcomes and immune dysfunction. Iron supplementation in adolescents has been linked to improvements in cognition, memory, and mood.

Testing recommendations were also updated. The AAP now advises screening with both a complete blood cell count and serum ferritin when feasible, rather than relying solely on hemoglobin measurements. With the addition of these biomarkers “pediatricians can increasingly use laboratory tools that are more biologically connected to iron availability,” Vangarsse said.

The report also expanded ferritin thresholds for diagnosing iron deficiency: a child younger than 12 years of age can now be diagnosed if their serum ferritin level is ≤ 20 ng/mL, whereas teens and girls who have begun menstruation now have a cutoff of ≤ 30 ng/mL.

“Higher thresholds will certainly lead to more proactive therapy,” De Oliveira said. “Many high-risk patients have ferritin levels that appear borderline normal despite a chronic predisposition to iron deficiency.”

The report recommends once daily ferrous sulfate dosing for both children and teens. Previous guidance emphasized the role of vitamin C in enhancing absorption , but new guidance notes that vitamin C co-administration is not required. Children should receive 3 mg/kg/d of elemental iron while adolescents should receive 65 mg/d.

For severe iron deficiency anemia, clinically stable children with hemoglobin levels < 7 g/dL may be managed with oral iron therapy and close outpatient follow-up, whereas transfusion should be reserved for patients who are clinically unstable, the recommendations state.

AAP includes recommendations for intravenous iron therapy for patients who do not respond adequately to oral iron or who have conditions that impair iron absorption. The report noted that improvements in the safety profile or intravenous iron therapy have expanded its use in children and adolescents.

The sources in this article reported no disclosures.

Brittany Vargas is a journalist covering medicine, mental health, and wellness.