News|Articles|September 16, 2026
ASH Raises Ferritin Thresholds for Diagnosing Iron Deficiency
Author(s)Sydney Jennings
Fact checked by: Abigail Brooks, MA
New American Society of Hematology guidelines raise ferritin cutoffs to catch iron deficiency sooner, including pregnancy and inflammation, and add TSAT for clearer diagnosis.
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The American Society of Hematology (ASH) has issued its first evidence-based clinical practice guidelines for diagnosing
Among the 5 recommendations, ASH suggests diagnosing iron deficiency at ferritin levels of 20 ng/mL or lower in children aged 9 months to 4 years and 30 ng/mL or lower in most adults, menstruating individuals, and pregnant individuals. Previous thresholds were generally 12 ng/mL in young children and 15 ng/mL in adults.¹
For adults with anemia of inflammation, the panel recommends evaluating both serum ferritin and transferrin saturation (TSAT), rather than relying on ferritin alone. Iron deficiency may be considered when ferritin is less than 100 ng/mL or TSAT is less than 20%.¹
“These updated ferritin thresholds provide clear guidance in an area where consensus has been lacking,” guideline chair Jacquelyn M. Powers, MD, MS, said in an ASH press release.²
New Ferritin Thresholds by Population
ASH developed the recommendations to address inconsistent laboratory reference ranges and diagnostic practices that may delay recognition of iron deficiency. The condition can produce fatigue, pica, irritability, impaired concentration, headache, and restless legs syndrome before hemoglobin levels decline.¹
The recommended thresholds include:
- Children aged 9 months to 4 years: Ferritin of 20 ng/mL or lower, rather than 12 ng/mL or lower. This threshold applies to children without known or suspected inflammation.
- Adults who are not menstruating or pregnant: Ferritin of 30 ng/mL or lower, rather than 15 ng/mL or lower. A threshold of 50 ng/mL or lower may be appropriate in patients with symptoms or ongoing risk factors for iron deficiency.
- Menstruating individuals: Ferritin of 30 ng/mL or lower. A threshold of 50 ng/mL or lower may be appropriate in patients with heavy or abnormal uterine bleeding, iron deficiency symptoms, additional risk factors, upcoming surgery, or plans for pregnancy.
- Pregnant individuals: Ferritin of 30 ng/mL or lower. In pregnant patients with anemia, a threshold of 50 ng/mL or lower may be appropriate regardless of whether other symptoms or risk factors are present.
- Adults with anemia of inflammation: Concurrent ferritin and TSAT testing. Iron deficiency may be considered with ferritin below 100 ng/mL or TSAT below 20%.
For children older than 4 years who have not reached adolescence, the panel considered 20 ng/mL or lower appropriate based on indirect evidence. For nonmenstruating adolescents, a ferritin level below 30 ng/mL may be used. No recommendation was made for children with inflammation because of insufficient evidence.¹
Inflammation Changes Ferritin Interpretation
Ferritin is an acute-phase reactant and may be normal or elevated in patients with inflammatory conditions despite depleted iron stores. Consequently, ASH suggests adding TSAT when evaluating adults with anemia associated with inflammatory bowel disease, chronic kidney disease, cancer, heart failure, rheumatologic disease, infectious disease, or other inflammatory disorders.¹
The panel advised obtaining TSAT after fasting for 5 to 9 hours, including avoidance of iron-containing supplements, because recent dietary intake can affect the result.
ASH also emphasized that anemia of inflammation may coexist with other causes of anemia. Ferritin and TSAT should therefore be interpreted alongside the patient’s history, physical examination, underlying disease, and condition-specific management guidelines.
Menstrual History Remains Essential
For menstruating patients, the guidelines include a good practice statement calling for a detailed menstrual history to identify abnormal uterine bleeding, particularly heavy menstrual bleeding. When abnormal bleeding is detected, clinicians should evaluate and address its underlying cause rather than treating iron deficiency alone.¹
This recommendation may be particularly relevant to primary care because patients do not always recognize their menstrual blood loss as excessive. Iron deficiency should also be considered before surgery and pregnancy, when untreated deficiency may increase the risk of complications or progression to anemia.
Most Recommendations Based on Limited Evidence
The multidisciplinary panel conducted systematic evidence reviews through July 2025 and used the GRADE framework to assess evidence certainty. All 5 recommendations were conditional and supported by low or very low-certainty evidence, except for the strong recommendation against using the lower 15-ng/mL threshold during pregnancy. That recommendation was also based on low-certainty evidence.¹
The authors acknowledged limited direct evidence linking specific ferritin thresholds to patient-important outcomes. The new cutoffs prioritize identifying patients whose iron deficiency might otherwise be missed, while additional research is needed to clarify optimal thresholds across age groups, pregnancy stages, and inflammatory conditions.
For primary care clinicians, the guidelines support evaluating iron deficiency independently of anemia and reconsidering results previously categorized as normal but falling within the newly recommended ranges. A diagnosis should prompt both iron replacement when appropriate and investigation of the underlying cause, including dietary insufficiency, gastrointestinal blood loss or malabsorption, abnormal uterine bleeding, pregnancy-related requirements, or chronic inflammation.
References
- Powers JM, Lim MY, Achebe MO, et al. American Society of Hematology 2026 guidelines for diagnosis of iron deficiency. Blood Adv. Published online September 16, 2026.
doi:10.1182/bloodadvances.2025015950 - American Society of Hematology. ASH sets new standards for diagnosing iron deficiency. News release. September 16, 2026. Accessed September 16, 2026.
https://www.hematology.org/newsroom/press-releases/2026/ash-sets-new-standards-for-diagnosing-iron-deficiency
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