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. Author manuscript; available in PMC: 2017 Feb 1.
Published in final edited form as: J Am Assoc Nurse Pract. 2015 May 5;28(2):116–120. doi: 10.1002/2327-6924.12268

Ask about ice, then consider iron

Antoinette Rabel 1, Susan F Leitman 2, Jeffery L Miller 1
PMCID: PMC4635104  NIHMSID: NIHMS680663  PMID: 25943566

Abstract

Background and purpose

To review a condition defined by the desire to consume ice in order to satisfy an addictive-like compulsion, rather than for purposes of hydration or pain relief. This condition is called ice pica, or pagophagia. Explain the association between ice pica and iron deficiency. Suggest to clinicians how to perform clinical screening for patients at risk for ice pica. Recommend treatment and follow-up care, if needed.

Methods

Extensive published literature review of original research articles, reviews, clinical practice manuscripts and scientific publications on pica and pagophagia.

Conclusions

A compulsion or craving for the consumption of ice is often overlooked in clinical practice. It is therefore important for clinicians to include ice pica as part of the review of systems for certain patient populations. Ice pica is frequently associated with iron deficiency, and iron supplementation is an effective therapy in most cases.

Implications for practice

Knowledge gained from screening for ice pica can generate valuable patient information and lead to the diagnosis and treatment of iron deficiency. The populations at risk include young women and blood donors of either sex.

Keywords: Pica, iron deficiency

Introduction

The word pica is derived from the Latin word for magpie, a bird that has an indiscriminate appetite (Halsted, 1968). Pica is loosely defined by a chronic compulsion to ingest non-nutritive materials (Barton, Barton & Bertoli, 2010), with the intensity of this desire described as an insatiable urge or “devouring passion” to eat such items (Spencer et al., 2013). While its pathogenesis is still not understood (Crosby, 1971), pica has been recognized as a medical entity for over 2000 years. Around 400 BCE, Hippocrates noted: “If a pregnant woman feels the desire to eat earth or charcoal and then eats them, the child will show signs of these things” (Woywodt & Kiss, 2002). At the beginning of the 15th century, de Cervantes reported a history in which “women that by caprice eat soil, plaster, coal and other disgusting substances” (Barton et al., 2010). Today, pica cravings are regularly compared to tobacco, alcohol, or other drug addictions (Young, 2010; Njiru, Elchalal, & Paltiel, 2011) based on the unrelenting, intrusive nature of the desires. The items consumed for pica may vary according to race/ethnicity, culture, and particular region (Barton et al., 2010; Njiru, Elchalal, & Paltiel, 2011). The three most commonly consumed substances world-wide are ice (pagophagia), cornstarch (amylophagia), and clay (geophagia) (Mills, 2007). Among these three, ice is the most commonly reported pica craving observed in the U.S. (Brown & Dynment, 1972; Lee et al., 2012). Clay consumption remains an accepted adaptive behavior at the present time in some cultures (Reid, 1992; Louw et al., 2007).

Types of pica are named from the Greek words of the ingested substance (Moore, & Sears, 1994). Ice pica is articulated by the medical community using the term pagophagia, based on the Greek words pagos meaning “frost” or “ice” and phagein meaning “to eat” (Coltman, 1969; Brown & Dynmet, 1972). According to Stedman's Medical Dictionary (28th ed., 2006), pagophagia is defined as “compulsive and repeated ingestion of ice.” Of note, the absence of teeth for chewing ice does not prevent pagophagia (Rector, 1989). Since a variety of ice types (cubed, crushed) and sources (home, work, restaurants) are available in modern culture, more quantitative definitions for pagophagia remains elusive. An early study of pagophagia defined the disorder as daily consumption of 2-11 full glasses of ice (480-2640 g) (Reynolds et al., 1968). Another study defined ice pica as “the purposeful ingestion of at least one ordinary tray of ice daily for a period in excess of two months” (Coltman, 1969). The average ice tray, at that time, contained 710 grams (1.6 pounds) of ice. A more recent study recommended more precise counts and duration of ice cube consumption to make the diagnosis (Khan & Tisman, 2010). Volume-equivalents of ice have also been used to identify patients with extremely large ingestion habits (ten liters of water equivalent daily) (Crosby, 1976). Reports may also alter the definition of pagophagia to accommodate auto-defrosters and ice cube makers or special circumstances such as ingesting ice from bottled water containers that have been frozen (Khan & Tisman, 2010) or flavored frozen water forms like popsicles (Barton, Barton & Bertoli, 2010). Recently, more emphasis was placed upon the “compulsive and nonrelenting” craving for ice, rather than the absolute quantity consumed. This review will focus on ice pica, with an emphasis on its common association with iron deficiency.

The etiology and molecular basis for all forms of pica, including pagophagia, are not well-understood. However, excessive consumption of ice is frequently associated with iron deficiency. One hypothesis suggests that non-food items are consumed to correct deficiencies in iron, calcium, zinc or other micronutrients. However, this theory does not explain pagophagia, since ice contains almost no iron. A more recent hypothesis suggests that chewing ice elicits a vasoconstrictive response that results in increased perfusion of the brain. This may lead to increased alertness and processing speed in subjects with iron-deficiency anemia, who frequently experience sluggishness and decreased ability to concentrate due to a decrease in oxygen delivery to the brain. In support of this hypothesis, chewing ice was found to markedly improve response times on neuropsychological tests in iron deficient anemic subjects but not in healthy controls (Hunt, Belfer & Atuahene, 2014).

At risk populations

A main goal of this review is to emphasize the important association between ice pica and iron deficiency (Brown & Dynment, 1972; Lee et. al., 2012). One of the original studies of this association involved active duty Air Force personnel or their dependents referred to a military hematology clinic from 1966 – 1967 with iron deficiency anemia due to chronic blood loss. Hemoglobin values in these subjects ranged from 5.0 - 10.2 g/100 mL, and fasting serum iron values ranged from 0 – 52 micrograms/100 mL. Pagophagia was reported in 23 of 38 (60%) consecutive patients, and their ice cravings resolved completely with iron supplementation (Reynolds, 1968). In a separate study, 28 of 55 (51%) patients with iron deficiency had pagophagia (Rector, 1989). Among blood donors, 29 percent of donors with iron depletion or deficiency were diagnosed with pica, mainly pagophagia (Bryant et al., 2013). Interestingly, an additional four percent of blood donors were identified as having pagophagia in the absence of iron deficiency.

Recognition of the close relationship between ice pica and iron thus provides a valuable tool with which to identify at risk populations. Menstruating (Coltman, 1969), pregnant (Thihalolipavan, Candella, & Ehrlich, 2013; Lopez et al, 2012) and lactating women (Parry-Jones, 1992; Osman, Wali, & Osman, 2005) are commonly at risk for ice pica due to the high prevalence of iron deficiency in these groups. Iron deficiency due to blood loss also occurs among blood donors (Bryant et al, 2012) and patients who have undergone major trauma or surgery (Dumitriu et al., 2013), or after hemorrhage from nasal, oral, gastrointestinal or renal compartments (Reynolds 1968; Rector, 1989; Khan & Tisman, 2010; Johnson-Wimbley & Graham, 2011). Iron deficiency may also result from inadequate dietary iron utilization, or malabsorption of iron, among patients with celiac disease or H. pylori infection (Asma et al., 2009; Rose, Pocerelli, & Neale, 2000; Johnson-Wimbley & Graham, 2011), or after gastric-bypass surgery (Louw et al., 2007; Marinella, 2008; Moize et al., 2010).

While iron deficiency is thus commonly associated with ice pica, pagophagia is not always caused by an iron disorder. While less common, autism spectrum disorder, dementia, mental retardation, and psychosis have been associated with pagophagia alone or in combination with other compulsive eating behaviors (Louw, et al., 2007; Miyakawa et al., 2011; Bhatia & Kaur, 2014). In those cases, pica may be considered a self-injurious behavior. Of course, ice may be normally consumed as a response to thirst or in response to physical exertion or warm weather. Ice may additionally serve as an analgesic for glossitis, xerostomia or other oral insults (Kettaneh et al., 2005). Ice chewing may be more effective than drinking cold water for xerostomia relief (Schorer, 1971). However, the vast majority of persons with pagophagia do not complain of oral pain, so pain relief is not likely to be a major cause of the disorder.

Identifying patients with ice pica in the outpatient setting

As clinicians, we should specifically address pagophagia or other forms of pica in our patient populations (Marinella, 2008). In the absence of a chemical or other diagnostic test for pagophagia, we propose the consideration of pagophagia as part of the nutritional review of systems for populations at risk for iron deficiency. We recommend that the interviewer begin by explaining the association between ice consumption and iron deficiency as discussed above. It may take persistence to elicit an accurate history, as patients are sometimes anxious regarding their compulsion to eat ice (Crosby, 1976). They may be secretive or reluctant to spontaneously mention their ice craving. They may not be aware that such behavior should be reported as a health problem (Rose, Porcerelli, Neal, 2000). Alternately, they may view ice pica as a normal, non-idiosyncratic behavior (Rector, 1989). Examination of other patient approaches in suspected cases of ice pica may also be helpful for patients who are reluctant to disclose their cravings (Crosby, 1971). The clinician may have to be persistent and inquisitive with pagophagia questioning. Consider asking related questions in a variety of ways. It may be very hard to gain this information from patients since it is usually not volunteered. Once the topic is introduced, questioning should be direct, focused on pagophagia, and should lead to further evaluation if affirmative responses are received. A summary of this approach is provided in Table I.

Table I. Pagophagia interview for at-risk groups.

1) Begin by explaining the relationship of ice consumption to iron deficiency.
2) Explain other ice consumption cases you have encountered where the patient was reluctant to disclose the cravings (Crosby, 1971).
3) Ask direct, pagophagia-related questions.
Examples: Do you crave ice?
Would it upset you if you were unable to chew ice every day?
Do your family or friends think that you chew too much ice?
4) If the responses above are affirmative, ask more specific questions.
Examples: Do you prefer any particular types of ice?
How long have you craved ice?
How much ice do you chew each day?
5) If the patient answers yes to any of the pagophagia questions, iron deficiency should be suspected and evaluated.
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Clinical management of ice pica due to suspected iron deficiency

Health history screening to elicit sources of acute and chronic blood loss, or to detect causes of dietary iron malabsorption, and laboratory screening to detect iron depletion and deficiency, are recommended in all patients with pagophagia. Importantly, laboratory results associated with decreasing iron stores usually occur before the onset of anemia (Alleyne, Horne, Miller, 2008, Table II). As iron deficiency develops (in cases of chronic rather than acute blood loss), ferritin levels will decrease before changes in the hemoglobin occur, since ferritin is a measure of total body iron stores. By the time the hemoglobin starts to fall, the ferritin value is generally less than 30 micrograms per liter. However, inflammation-related processes can increase ferritin levels and may confound the interpretation of this test in patients who are iron depleted (Cook, 1982; Johnson-Wimbley & Graham, 2011; Powers & Buchanan, 2014). Low transferrin saturation levels (less than 16%) are also used to diagnose iron depletion or deficiency (Cook, 1982). This laboratory test indicates the relative amount of iron that is bound to its transporter in the blood. When the patient's iron stores are no longer sufficient to support the production of adequate amounts of heme, a reduction in hemoglobin production occurs that ultimately results in anemia. At this stage, the depleted iron stores reach the stage of deficiency, and the red blood cell count and mean corpuscular volume (MCV) are also reduced. The most common single laboratory value associated with pica is a low red cell MCV (Bryant et al., 2013). Without iron replacement therapy, the extent of laboratory abnormalities and anemia may become severe.

Table II. Laboratory values associated with iron deficiency/depletion.

Laboratory Test Value Indicative of Iron Deficiency
Ferritin Less than 30 mcg/dL
Serum iron Less than 50 mcg/dL
Transferrin saturation (T-sat) Less than 15%
Total iron-binding capacity (TIBC) Greater than 450 mcg/dL
Red cell count (RBC) Less than 4 × 106 /mm3
Red cell distribution width (RDW) Greater than 14.5%
Mean corpuscular volume (MCV) Less than 80 fL
Hemoglobin (Hgb) Less than 13 g/dL, males
Less than 12 g/dL, menstruating females
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Adapted from Alleyne et al, 2008, modified per Kiss et al, (2013).

If iron depletion or deficiency is detected, the patient should be evaluated to determine the cause of iron deficiency, and iron replacement therapy should be provided. Current approaches to oral or intravenous iron supplementation were summarized in a recent review (Powers and Buchanan, 2014). In general, oral iron supplements are the first choice for initial therapy of iron deficiency due to their safety, low cost and effectiveness in restoring iron levels. Oral iron preparations containing ferrous sulfate, ferrous gluconate, or ferrous fumarate are available over-the-counter as well as by prescription. They contain between 38 to 100 mg of elemental iron per tablet. The replacement dose is generally one tablet daily and is best absorbed on an empty stomach. More severe degrees of iron deficiency anemia may require increasing the dose to two to three tablets daily for at least the first month; however, higher oral doses are associated with greater gastrointestinal adverse effects. Complete replacement of absent body iron stores occurs gradually and generally requires at least four to six months of oral therapy, assuming the cause of the iron deficiency has been remedied. As the incidence of mild to moderate gastrointestinal discomfort is common, occurring in as many as 20% of persons taking oral iron supplements, regular follow-up of the patient is essential to ensure compliance (Bryant et al, 2013). A second option is parental iron therapy for those subjects who cannot be adequately treated with or cannot tolerate oral preparations. In the U.S., there are currently several intravenous iron preparations approved for use in patient treatment. The preparations have varying iron concentrations, infusion times, and hypersensitivity rates (Powers & Buchanan, 2014). Many clinicians are not accustomed with prescribing intravenous iron (Silverstein & Rodgers, 2004). Clinical consultation with a hematologist or pharmacist is recommended before parental iron is given to ensure that the most effective and least toxic regimen is provided when parenteral therapy is appropriate.

In the absence of ongoing blood loss or other causes of anemia, iron supplementation should cause normalization of the hematocrit and increased ferritin to reference range levels (in healthy adults, a ferritin level of 50 – 100 micrograms/L corresponds to 400 – 800 mg iron in body stores). During the period of iron replacement therapy, the subject should be re-evaluated to determine whether the pagophagia resolved. Usually, the compulsion to chew ice resolves within a few days to weeks after beginning iron replacement therapy, possibly due to the repletion of iron in cerebral tissues (Osman, Wali, & Osman, 2005). In a recent study of blood donors, pagophagia completely disappeared by day 14 of oral iron supplements, even though body iron stores were not fully replaced. Even as early as days 5 to 8 of therapy, the blood donors reported a decrease in the craving of ice (Bryant et al., 2013). If resolution of the iron deficit does not cause the pagophagia to abate, alternate causes should be considered with further evaluation tailored for the individual patient.

Summary

Pagophagia, the compulsive craving and over-consumption of ice, remains a curious, reversible disorder that is frequently overlooked in the clinic. As shown in Figure 1, the approach to pagophagia is straightforward, and begins with inclusion of pica-oriented questions in the review of systems. In particular, menstruating females, or patients who have experienced significant blood loss from hemorrhage or phlebotomy (blood donors), are at highest risk for this disorder. Once a history of pagophagia is confirmed, all patients should be evaluated for iron deficiency. If iron deficiency is diagnosed, iron repletion is likely to completely resolve the craving for ice. For those patients who are not iron deficient, or for whom iron repletion does not resolve the pica, consideration must be given to other etiologies including neurologic or psychiatric disorders. The most important takeaway from this review is to simply ask about ice consumption in at-risk populations as a clinical screening tool for iron deficiency.

Figure 1.

Figure 1

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Acknowledgments

This research was supported by the Intramural Research Program of the NIH, NIDDK.

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