Why Chewing Ice May Be a Sign of Anemia in Kids

Ice cubes in colorful trays

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Kids are sometimes given ice chips when they are sick, especially when recovering from surgery. It may surprise some parents that chewing ice can also be a sign that your child is ill. When the chewing of ice becomes compulsive or includes non-food items (such as paper, soil, or clay), it may be the sign of a condition known as iron deficiency anemia.

Iron Deficiency Anemia

Iron deficiency anemia is a form of anemia that occurs when you don't have enough iron in your body. Iron is important in the formation of red blood cells and hemoglobin (an iron-containing molecule that transports oxygen throughout the body).

Iron deficiency anemia tends to develop slowly because the body usually has ample reserves in the bone marrow and liver. Once these reserves are significantly depleted, the production of red blood cells and level of hemoglobin in the blood can plummet, leading to the characteristics 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

Iron deficiency anemia can be caused by nutritional deficiency, pregnancy, excessive menstrual bleeding, gastrointestinal bleeding, malabsorption disorders (such as celiac disease), recent blood donation, and parasitic intestinal worms.

The most common cause of iron deficiency in children is the insufficient intake of iron in conjunction with rapid growth spurts.

Cow's milk can also interfere with the absorption of iron and cause the body to lose small amounts of blood. Drinking excessive quantities of cow's milk can sometimes cause iron levels to drop in infants and toddlers.

Symptoms in Children

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

A lesser-known symptom is pica, a disorder characterized by an appetite for non-nutritive or non-food items such as rocks, soil, drywall, paint chips, paper, uncooked flour, uncooked rice, and chalk. Pica occurs more frequently in children than in adults, although pregnant women and recent blood donors are also commonly affected.

Although pica is largely considered a psychological disorder (such as with obsessive-compulsive disorder), it is believed that children with iron deficiency anemia will sometimes chew on ice and other items due to a craving for iron.

Of all of the items children with iron deficiency might chew on, ice is by far the most characteristic. This distinctive form of pica, known as pagophagia, is believed to affect roughly half of all people who are iron deficient.

Causes of Pagophagia

Pagophagia and other forms of pica are not well understood. Within the context of iron deficiency, it is believed that pagophagia may occur in response to acute nutritional deficiencies. This is evidenced in part by studies that have shown that iron supplementation can reverse pica and other symptoms (such as restless legs) in recent blood donors.

Proponents of the theory contend that pagophagia is more likely in parts of the world with a high concentration of minerals in the water (referred to as "hard water"). With that said, there are far better sources of iron than hard water, and many doubt that nutritional cravings alone account for the high incidence of the disorder.

Others have hypothesized that iron deficiency simply triggers an underlying disorder of the central nervous system, leading to the abnormal craving of ice or other non-nutritive substances.

Others still believe that chewing ice may be a subconscious way of soothing glossitis (inflammation of the tongue) and stomatitis (inflammation of the mouth) characteristic of iron 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. It is a chicken-and-egg situation for which there are few definitive answers.

Though pagophagia is considered a symptom of iron deficiency, it is not always caused by an iron disorder. Children with autism and teens and adults with compulsive eating disorders have also been known to experience pagophagia.

What to Do

If you see your child chewing ice compulsively, you should never ignore the behavior or dismiss it as a "tic." While it is perfectly normal for kids to chew on ice when it's hot or after a sweet drink, pagophagia is more than just an occasional habit. It is a condition in which the chewing of ice is excessive, with some researchers reporting consumptions of up to a tray of ice per day for months at a time.

The very act of chewing ice should be of concern to parents, as it can crack still developing teeth. Other objects such as paint chips can expose a child to lead poisoning.

If your child chews ice and has risk factors for iron deficiency (including poor eating habits), schedule an appointment with your pediatrician and ask that iron deficiency anemia be explored. This would involve blood tests to measure red blood cells, hemoglobin, iron, and ferritin (a blood protein that contains iron).

According to research, the single most common lab value associated with pica is a low red cell mean corpuscular value (MCV).

If iron deficiency anemia is diagnosed, your pediatrician may recommend iron-rich foods to increase reserves in the body.

Iron supplements may also be prescribed in tablet or liquid form but should only be used under strict medical supervision. The overuse of iron supplements in children can lead to hemochromatosis (iron overload), which can cause severe abdominal pain, weakness, liver injury, lung inflammation, and cardiomegaly (an enlarged heart).

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