An Overview of Pagophagia

Ice cubes in colorful trays

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Pagophagia is a term used to describe the compulsive eating of ice. Although it is regarded as a form of pica (a psychological disorder characterized by the consumption of non-food items like hair and paper), pagophagia may also be a sign of iron deficiency anemia, a condition in which a lack of iron causes a drop in healthy red blood cells.

Symptoms

The primary symptom of pagophagia is the compulsive consumption and chewing of ice. This cause may be psychological but may also as a physiological response to iron deficiency anemia.

Pagophagia as a Form of Pica

When pagophagia occurs as a form of pica, it can easily be missed by anyone who is not annoyed or disturbed by the behavior. Moreover, because the consumption of ice is usually not dangerous, there won't any of the severe symptoms commonly seen in people who compulsively eat clay, rocks, or paint chips (such as stomach pain, constipation, diarrhea, vomiting, or bloody stools).

The one problem that can occur with pagophagia is tooth damage. This is especially true in children with developing teeth. Chewing ice habitually can damage tooth enamel and lead to problems such as tooth pain and increased cold sensitivity. Many people with pagophagia aren't even aware of the problem until fillings need replacement or a tooth suddenly chips.

Pagophagia and other forms of pica are by nature habitual but may worsen when there are additional stresses in one's life.

One of the classic tell-tale signs of pica-associated pagophagia is the relentless chewing of ice even when teeth are damaged or missing.

Pagophagia and Iron Deficiency Anemia

Pagophagia is an entirely different issue if it occurs as a result of iron deficiency. Iron deficiency anemia is a form of anemia that occurs when you don't have enough iron in your body. Iron is essential to the formation of red blood cells as well as hemoglobin (an iron-containing molecule that carries oxygen throughout the body).

Iron deficiency tends to develop slowly because the body usually has ample reserves in the bone marrow and liver. When iron levels start to plummet, pagophagia can sometimes be an early, albeit commonly missed, a sign of deficiency.

When pagophagia occurs with iron deficiency, the consumption of ice will start with a sudden craving and worsen in tandem with the depletion of iron. Pagophagia is generally not associated with other forms of anemia, such as hemolytic anemia, pernicious anemia, or aplastic anemia.

When caused by iron deficiency anemia, pagophagia will likely occur in tandem with the classic symptoms of anemia, including:

  • Fatigue
  • Lightheadedness
  • Weakness
  • Headaches
  • Pale Skin Color
  • Shortness of Breath
  • Irritability
  • Low Exercise Tolerance
  • Heart Palpitations
  • Chest Pain
  • Inflammation of the Tongue
  • Difficulty Swallowing
  • Restless Leg Syndrome

The symptoms of iron deficiency anemia in children can differ from those in adults. One of the characteristic signs in kids is the lightening of mucous membranes inside the mouth, on the tongue, and most especially on the inner eyelids and conjunctiva (whites of the eyes).

Causes

As with the symptoms of pagophagia, the causes of pagophagia may be either psychological or physiological.

Psychological Causes

The occasional chewing of ice is not in itself an indication of pagophagia. Pica, by definition, is the abnormal and excessive eating of non-nutritive substances, including ice, for longer than one month that is "inappropriate to the development of the individual." Simply put, it is a behavior that is both disruptive to one's health or well-being and compulsive (meaning that you are unable to stop the behavior even if you are aware of it).

To provide some context as to the potential scale of the problem, some researchers have noted the consumption of at least one tray of ice per day in people with pagophagia. Some cases are even more extreme, manifesting with dental injury, tooth loss, and nutritional deficiencies.

According to the American Psychiatric Association (APA), feeding and eating disorders, including pica, are closely aligned with obsessive-compulsive disorder (OCD). Stress almost invariably makes symptoms worse.

It is not uncommon for pagophagia to occur with other forms of pica, including geophagia (the eating of dirt), amylophagia (starch), lithophagia (rocks), trichophagia (hair, wool, and other fibers).

Children and adults with autism will often experience pagophagia and other forms of pica as part of a repetitive, and therefore psychologically comforting, behavior.

Iron Deficiency

Within the context of anemia, pagophagia can develop in response to acute iron deficiency. This is evidenced in part by studies that have shown that iron supplementation can reverse symptoms of pica and anemia (including restless leg syndrome) in recent blood donors.

This is supported by research in which pica is more common in parts of the developing world where nutritional deficiencies are widespread. In the developed world, pagophagia is seen mainly in children, pregnant women, and people who have undergone gastric bypass surgery.

A common cause of iron deficiency in children is related to growth spurts in which the nutritional needs of a child are sharply increased. Similarly, in pregnant women, the need for oxygen is suddenly doubled as the baby rapidly grows. With gastric bypass, the surgery reduces the area of tissue through which nutrients, including iron, can be absorbed, leading to a deficiency.

On the flip side, there is evidence, albeit weak, that pagophagia and other forms of pica cause the nutritional deficiencies that lead to anemia. This includes eating disorders that commonly accompany pica, OCD, depression, and other mental health conditions.

It is unclear how common pagophagia is in people with iron deficiency anemia. Some studies suggest that roughly 13% are affected, while others have concluded that as many as one in three may experience these abnormal cravings.

Diagnosis

Diagnosing the cause of pagophagia is often difficult because people don't usually see a doctor until the behavior has begun to interfere with their lives. Unless there are other physical symptoms that need addressing, pagophagia as a psychological condition can go undiagnosed and untreated for years.

Diagnosing Pica

There are no lab tests to diagnose pagophagia or any other form of pica. The diagnosis is based on whether certain criteria are met in the APA's Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).

Key to this in the persistence of the behavior for more than a month. Other causes will also be considered (such as pregnancy and gastric bypass). Ideally, lab tests will be performed to determine if there is iron deficiency. If suspected, autism may also be explored.

If, in the process of diagnosis, pagophagia is suspected but blood tests are not performed, insist that they are done. This can prevent misdiagnosis and the inappropriate treatment of a physical rather than a psychological condition.

Diagnosing Iron Deficiency

Iron deficiency can readily be confirmed with blood tests. These tests will be among the first things a doctor will order if there are physical signs of anemia.

There are several tests a doctor can perform from a single blood draw to confirm a deficiency. These iron tests include:

  • Serum Iron
  • Serum Ferritin
  • Serum Transferrin
  • Total Iron-Binding Capacity (TIBC)
  • Transferrin Receptor Protein (TRP)
  • Transferrin Saturation Test (TSAT)

A complete blood count (CBC) will also be performed to measure the composition of blood cells in a sample of blood. Results from these tests can usually be returned within one to three business days, depending on the lab.

It is rare that pagophagia is the sole reason for a visit to a doctor unless the symptoms are so severe as to cause genuine distress. Though the individual may be referred to a psychiatrist or psychologist, it would arguably be more appropriate to perform blood tests first even if there are no overt symptoms.

Iron deficiency can occur without anemia, often as a result of abnormal blood loss due to abnormal menstrual bleeding, celiac disease, or even an H. pylori infection. In the end, if pagophagia is present, blood iron should be tested.

Treatment

The treatment of pagophagia is directed by the cause. Psychological causes tend to require extensive and sometimes ongoing care. Physical causes require the normalization of iron levels and the treatment of the underlying cause of the deficiency.

Pica

If pagophagia develops with no underlying physical cause, a referral to a psychiatrist or psychologist experienced in feeding and eating disorders should be considered.

Given that pagophagia doesn't run the health risks that some forms of pica do — like plumbophagia (the abnormal eating of lead) — there may be less need for medical interventions like lead chelation therapy. This doesn't mean that pagophagia therapy is any less concerning. Malnutrition is a common feature of pica and may require aggressive dietary interventions to prevent long-term harm.

One of the most common approaches to the treatment of feeding and eating disorders is cognitive-behavioral therapy (CBT) in which patterns of thinking or behavior are changed by working with a therapist to identify the root causes.

Currently, there are no medications approved for the treatment of pica. Some doctors have endorsed the use of Zyprexa (olanzapine), a drug ordinarily used for schizophrenia, to reduce the urge to eat nonfood items.

If pica is an extension of OCD, antidepressants like Anafranil (clomipramine), Luvox (fluvoxamine), Paxil (paroxetine), Prozac (fluoxetine), and Zoloft (sertraline) may be recommended.

Iron Deficiency

If mild iron deficiency anemia is diagnosed, your doctor may start by recommending iron-rich foods to replenish the iron reserves in the body. Iron supplements have proven especially effective for the treatment of pagophagia and other acute iron deficiency symptoms, including restless leg syndrome.

Another option is Injectafer (ferric carboxymaltose), an iron replacement treatment delivered intravenously (into a vein) for adults who do respond to or cannot tolerate oral iron supplements. If all else fails or the deficiency is caused by severe blood loss, a blood transfusion may be needed.

Additional treatments may be needed based on the underlying cause of iron deficiency.

Iron supplements should not be used on an ongoing basis unless directed by a doctor. Their overuse can cause hemochromatosis (iron overload), the condition of which can lead to severe abdominal pain, liver injury, lung inflammation, and cardiomegaly (an enlarged heart).

A Word From Verywell

That fact that you or someone you know chews ice shouldn't cause you alarm. In most cases, the habit may be irritating but is otherwise harmless. It is only when it becomes compulsive or excessive that you should consider seeing a doctor. In some cases, it may be the sign of iron deficiency, a condition that can usually be treated with supplements and/or changes in diet.

If the compulsion is interfering with a person's health or quality of life, it just as important to seek a diagnosis from qualified mental care professional. Pagophagia and other forms of pica rarely occur on their own and maybe a sign of a larger mental health condition in need of treatment.

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