Summary of Guidance for Pediatricians

Document Overview

Design and created by Guideline Central in participation with the American Academy of Pediatrics.

Prevention, Screening, Diagnosis, and Treatment of Iron Deficiency and Iron Deficiency Anemia in Infants, Children, and Adolescents

American Academy of Pediatrics

Publication Date: Jun 22, 2026

Page Last Updated: Jun 23, 2026

Exclusively breastfed term infants should receive iron supplementation (1 mg/kg/d) by 4 months of age. Alternatively, some caregivers may wish to wait until 6 months of age when complementary foods containing iron are introduced. Preterm infants (less than 37 weeks’ gestational age at birth) receiving full enteral feeds should begin iron fortification or supplementation by 2 weeks of life to ensure iron intake of 2 to 3 mg/kg/d. Children >6 months up to 5 years of age should receive sufficient quantities of iron-rich foods. Cow milk or milk alternatives, including plant-based milk, (in lieu of human milk or formula) should not be offered to any infant prior to 12 months of age. Children >1 year should drink less than 24 ounces per day of milk (cow milk and/or plant-based milk alternatives). School-aged children and adolescents should be encouraged to consume a variety of iron-rich foods.
Laboratory screening for ID and IDA, consisting of a CBC and SF, should occur in all infants and young children. Screening should occur at the time point at which the child is most at risk for ID, on the basis of the child’s primary source of nutrition during the first year of life.
- In infants whose primary source of nutrition is human milk, screening is recommended at 9 to 12 months of age.
- In infants whose primary source of nutrition is iron-fortified formula, screening is recommended at 15 to 18 months of age after transition to cow milk (or plant-based milk alternatives).
- If a CBC and SF cannot be obtained, at a minimum, Hb should be assessed.
- Children with ongoing risk factors, specifically excessive milk intake and/or inadequate intake of iron-containing complementary foods, should be rescreened for IDA at each subsequent well-child assessment until 4 years of age.
Universal laboratory screening for ID and IDA with a CBC and SF should be performed in all adolescents who are at least 1 year postmenarche but no later than 14 years of age. Screening thereafter should be performed in menstruating adolescents with clinical risk factors of excessive menstrual blood loss or low-iron diet.
For the majority of affected children and adolescents, a positive clinical history of IDA risk factors combined with a microcytic anemia confirms its diagnosis.
- SF≤20 ng/mL is consistent with ID in young and school-aged children.
- SF≤30 ng/mL is consistent with ID in adolescent and menstruating individuals.
- When combined with anemia, a low SF is consistent with IDA.
Treatment for children with IDA includes identifying and addressing the underlying etiology (ie, dietary changes, control of blood loss) as well as initiation of iron replacement therapy. In young children, initial therapy should consist of ferrous sulfate, 3 mg/kg elemental iron, administered once daily. In adolescents, initial therapy should consist of ferrous sulfate, 65 mg elemental iron, administered once daily.
Children with severe IDA (Hb <7 g/dL) who are clinically stable and in whom reliable follow-up can be ensured may receive oral iron therapy with close outpatient follow-up at 7 to 10 days, in addition to 1- and 3-month follow-up visits. Children who are clinically unstable with severe IDA should receive a blood transfusion administered slowly in small aliquots as well as the same diagnostic workup, iron therapy (for a minimum 3 months), and follow-up as those children not requiring transfusion.
All children with IDA should have, at minimum, follow-up visits at 1 and 3 months after initiation of therapy. In children with mild IDA, defined as Hb ≥9 g/dL, an appropriate response to therapy consists of normalization of the Hb at the 1-month follow-up visit. In children with moderate (Hb ≥7 to <9 g/dL) or severe IDA (Hb <7 g/dL), an adequate response to therapy consists of Hb increment of at least 2 g/dL at the 1-month follow-up. In such patients, oral iron therapy should be continued at the same therapeutic dosing for a minimum of 3 months. Patients with SF<20 ng/mL at the 3-month follow-up should continue iron supplementation for an additional 3 months.
In children with persistent microcytic anemia or recurrent IDA, the provider should: (1) confirm the diagnosis; (2) review the prior iron therapy; (3) assess success or barriers to taking medication; and (4) reevaluate the underlying etiology. IV iron therapy may be considered for children with inadequate response to oral iron therapy or in conditions impairing iron absorption, including chronic inflammatory disorders. Children in whom IV iron therapy is being considered should be referred to a pediatric specialty center with experience in parenteral iron administration, when available.

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Document Overview

Document Title: Prevention, Screening, Diagnosis, and Treatment of Iron Deficiency and Iron Deficiency Anemia in Infants, Children, and Adolescents

Authoring Society: American Academy of Pediatrics

Document Publication Date: Jun 22, 2026

Page Last Reviewed/Updated: Jun 23, 2026

Document Type: Consensus Statement

Country of Publication: United States

Full Text Freely Available: Yes

Full Text Guideline: publications.aap.org/pediatrics/article/doi/10.1542/peds.2026-077414/207901/Prevention-Screening-Diagnosis-and-Treatment-of

Source Citation: Powers JM, Heeney MM, Hord J, Lehmann CU, Abrams SA, Buchanan GR; 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 Jun 22:e2026077414. doi: 10.1542/peds.2026-077414. Epub ahead of print. PMID: 42324084.

Document Scope, Criteria, and Use Cases

Document Objectives: This clinical report includes strategies for the prevention of iron deficiency (ID) and iron deficiency anemia (IDA), updates for screening, as well as diagnostic and treatment recommendations. It relates broadly to children, from birth through adolescence, affected by either nutritional ID or IDA attributable to insufficient dietary iron, malabsorption, or loss of iron from heavy menstrual, gastrointestinal, or other external blood loss. Recommended diagnostic strategies emphasize important features of the history, physical examination, and informative laboratory tests available to both generalists and subspecialists. Treatment of children with ID, mild IDA, and moderate or severe IDA or when IDA is refractory or recurrent is discussed. Recommendations regarding oral iron therapy and intravenous iron treatment options are described.

Scope: Assessment and Screening, Diagnosis, Management, Prevention, Treatment

Keywords: iron deficiency, iron deficiency anemia

Inclusion Criteria: Male, Female, Adolescent, Adult, Infant

Health Care Settings: Ambulatory

Intended Users: Nurse, Nurse Practitioner, Physician, Physician Assistant

Prevention, Screening, Diagnosis, and Treatment of Iron Deficiency and Iron Deficiency Anemia in Infants, Children, and Adolescents

Summary of Guidance for Pediatricians

Table 1. Normal Hematologic Parameters in Infants, Children, and Adolescents by Age and Sex, From Age 9 Months to 18 Years

Table 2. Clinical History Consistent With or Concerning for Iron Deficiency or Iron Deficiency Anemia

Table 3. Differential Diagnosis of Children With Microcytic Anemia

Table 4. Indications for and Interpretation of Available Iron Parameters

Table 5. Potential Indications for IV Iron Therapy

Table 6. Intravenous Iron Formulations Available in the United States

Document Overview

Document Scope, Criteria, and Use Cases