Why "Normal" Ferritin Can Miss Iron Deficiency, With Jacquelyn Powers, MD, MS

Laboratory reference ranges that label very low ferritin values as normal are a major reason iron deficiency goes unrecognized, according to the chair of an American Society of Hematology (ASH) guideline panel. The panel is now pushing for laboratories to build the society's new thresholds directly into their reports.

"There are many different laboratory reference ranges that actually have values in the single digits that were flagged as normal, and many providers are very busy," said Jacquelyn M. Powers, MD, MS, guideline chair, section chief of hematology at Texas Children's Hospital, and associate professor of pediatrics at Baylor College of Medicine, in an interview with HCPLive. "They'll order a lab test. If it's not flagged, then they may say, 'Oh, everything's normal. I've ruled this out,' and now I'm going to put anything related to iron outside of my mind and look for something else."

The ASH guideline, published in Blood Advances, recommends a serum ferritin threshold of ≤30 ng/mL for most adults and ≤20 ng/mL for children aged 9 months to 4 years. A threshold of up to 50 ng/mL may be appropriate for some patients. The guideline addresses iron deficiency itself, whether or not anemia is present.¹,²

Why the Guideline Targets Iron Deficiency Without Anemia

Powers said the panel chose to address iron deficiency rather than iron deficiency anemia on purpose. Iron deficiency can cause subtle symptoms, and clinicians may dismiss them when a patient's blood count is normal.

Detecting iron deficiency early gives clinicians a chance to intervene before patients progress to anemia or continue to have symptoms. Powers said a central goal of the new thresholds is for more patients to be diagnosed, so that people who could benefit from iron therapy are not overlooked.

Building Ferritin Thresholds Into Laboratory Clinical Decision Limits

Powers said the panel is advocating for laboratories at institutions and national health organizations to adopt the new thresholds as clinical decision limits in their reference ranges. Results below the threshold would then be flagged automatically. She described this as an easy way to put the thresholds into practice and make it more feasible for clinicians to act on them.

Multidisciplinary Panel Aims for Consistent Iron Deficiency Care

The panel included pediatric and adult hematologists, a neonatologist, a maternal-fetal medicine specialist, a pharmacist, and a patient representative. Members also brought expertise in cost effectiveness, transfusion and laboratory medicine, and guideline implementation.

Powers, a pediatric hematologist whose clinical work and research focus on iron deficiency in young children and adolescents, said a key goal was consistency. She wants generalists, primary care clinicians, and specialists to apply the thresholds in the same way, so patients receive more equitable care regardless of where they are treated.

When a Ferritin Threshold of 50 ng/mL May Be Appropriate

"There are high risk patient populations or individuals who might have risk factors that would benefit from using a higher threshold, and that's really trying to capture some of the nuances, some of the symptoms that patients experience, or those patient populations for whom progressing very quickly from iron deficiency to iron deficiency anemia may occur unless they maintain a higher ferritin," Powers said.

Although ≤30 ng/mL is the recommended threshold for most adult populations, the guideline notes that a higher threshold may suit patients with heavy menstrual bleeding or symptoms consistent with iron deficiency.¹ Powers encouraged clinicians to apply the guidance to each patient individually.

Editor's Note: Powers reports no relevant disclosures.

References

1. Powers JM, Lim MY, Achebe MO, et al. American Society of Hematology 2026 guidelines for diagnosis of iron deficiency. Blood Adv. 2026. doi:10.1182/bloodadvances.2025015950

2. American Society of Hematology. ASH sets new standards for diagnosing iron deficiency. Medical Xpress. September 16, 2026. https://medicalxpress.com/news/2026-09-ash-standards-iron-deficiency.html