Rittenhouse Hematology Oncology

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ANEMIA

Iron deficiency anemia is a common type of anemia — a condition in which blood lacks adequate healthy red blood cells. Red blood cells carry oxygen to the body's tissues, giving your body energy and your skin a healthy color.

As the name implies, iron deficiency anemia is due to insufficient iron. Without enough iron, your body can't produce enough hemoglobin, a substance in red blood cells that enables them to carry oxygen. As a result, iron deficiency anemia may leave you tired, weak and pale.

You can usually correct iron deficiency anemia with iron supplementation. Sometimes, additional treatments for iron deficiency anemia are necessary, especially if you're bleeding internally.

Symptoms

Initially, iron deficiency anemia can be so mild that it goes unnoticed. But as the body becomes more deficient in iron and anemia worsens, the signs and symptoms intensify.

Iron deficiency anemia symptoms may include:

  • Extreme fatigue
  • Pale skin
  • Weakness
  • Shortness of breath
  • Headache
  • Dizziness or lightheadedness
  • Cold hands and feet
  • Irritability
  • Inflammation or soreness of your tongue
  • Increased likelihood of infections
  • Brittle nails
  • Irregular heartbeat (arrhythmia)
  • Unusual cravings for non-nutritive substances, such as ice, dirt or pure starch
  • Poor appetite, especially in infants and children with iron deficiency anemia
  • Restless legs syndrome — an uncomfortable tingling or crawling feeling in your legs

When to see a doctor
If you or your child develops signs and symptoms that suggest iron deficiency anemia, see your doctor. Iron deficiency anemia isn't something to self-diagnose or treat. Take iron supplements only with a doctor's supervision. Overloading the body with iron can be dangerous because excess iron accumulation can damage your liver and cause other complications.

Causes

Normally, your body uses iron from the food you eat or recycled iron from old red blood cells to produce hemoglobin. Hemoglobin is the part of red blood cells that gives blood its red color and enables the red blood cells to carry oxygenated blood throughout your body.

If you aren't consuming enough iron, or if you're losing too much iron, your body can't produce enough hemoglobin, and iron deficiency anemia will eventually develop.

Common reasons that iron deficiency anemia develops include:

  • Blood loss. Blood loss is the most common cause of iron deficiency anemia in the United States and Western Europe. The reason is that blood contains iron within red blood cells. So if you lose blood, you lose some iron. Women with heavy periods are at risk of iron deficiency anemia because they lose a lot of blood during menstruation. Slow, chronic blood loss within the body — such as from a peptic ulcer, a kidney or bladder tumor, a colon polyp, colorectal cancer, or uterine fibroids — can cause iron deficiency anemia. Gastrointestinal bleeding can result from regular use of aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs). Tell your doctor if you notice blood in your urine or stools.
  • A lack of iron in your diet. Your body regularly gets iron from the foods you eat. If you consume too little iron, over time your body can become iron deficient. Examples of iron-rich foods include meat, eggs, dairy products or iron-fortified foods. For proper growth and development, infants and children need iron from their diet, too.
  • An inability to absorb iron. Iron from food is absorbed into your bloodstream in your small intestine. An intestinal disorder, such as Crohn's disease or celiac disease, which affects your intestine's ability to absorb nutrients from digested food, can lead to iron deficiency anemia. If part of your small intestine has been bypassed or removed surgically, that may affect your ability to absorb iron and other nutrients. Some medications can interfere with iron absorption. For example, regular use of medications that decrease stomach acid may lead to iron deficiency anemia. Your body needs stomach acid, which these products suppress, to convert dietary iron into a form that can readily be absorbed by the small intestine.
  • Pregnancy. Without iron supplementation, iron deficiency anemia occurs in many pregnant women because their iron stores need to serve their own increased blood volume as well as be a source of hemoglobin for the growing fetus. A fetus needs iron to develop red blood cells, blood vessels and muscle.
Risk factors

These factors may increase the risk of iron deficiency anemia:

  • Heavy menstrual periods
  • Pregnancy
  • A diet consistently low in iron
  • A known or hidden source of bleeding within your body, such as an ulcer, a bleeding tumor, a uterine fibroid, a colon polyp, colorectal cancer or gastrointestinal bleeding.

These groups of people may be at higher risk:

  • Women. Because women lose blood during menstruation, women in general are at greater risk of iron deficiency anemia.
  • Infants and children. Infants, especially those who were low birth weight or born prematurely, who don't get enough iron from breast milk or formula may be at risk of iron deficiency. Children need extra iron during growth spurts, because iron is important for muscle development. If your child isn't eating a healthy, varied diet, he or she may be at risk of anemia.
  • Vegetarians. Because vegetarians don't eat meat, they're at greater risk of iron deficiency anemia. Iron that comes from grains and vegetables isn't absorbed by the body as well as is iron that comes from meat.

In healthy men and postmenopausal women, iron deficiency usually indicates bleeding somewhere in the gastrointestinal tract.

Donating blood — a source of blood loss — isn't a common risk factor for iron deficiency anemia unless you've given blood repeatedly over a short time. However, some people first learn their hemoglobin is low, which indicates anemia, when they offer to donate blood. Low hemoglobin may be a temporary problem remedied by eating more iron-rich foods. It may also be a warning sign of blood loss in your body. If you're told that you can't donate blood because of low hemoglobin, ask your doctor whether you should be concerned.

Complications

Mild iron deficiency anemia usually doesn't cause complications. However, left untreated, iron deficiency anemia can become severe and lead to health problems, including the following:

  • Heart problems. Iron deficiency anemia may lead to a rapid or irregular heartbeat. Your heart must pump more blood to compensate for the lack of oxygen carried in your blood when you're anemic. In people with coronary artery disease — narrowing of the arteries that supply the heart — unchecked anemia can lead to angina. Angina is chest pain caused by decreased oxygen and blood flow to the heart muscle.
  • Problems during pregnancy. In pregnant women, severe iron deficiency anemia has been linked to premature births and low birth weight babies. But the condition is easily preventable in pregnant women who receive iron supplements as part of their prenatal care.
  • Growth problems. In infants and children, severe iron deficiency can lead to anemia as well as delayed growth. Untreated iron deficiency anemia can cause physical and mental delays in infants and children in areas such as walking and talking. Additionally, iron deficiency anemia is associated with a greater incidence of lead poisoning and an increased susceptibility to infections.
Preparing for your appointment

If you think you may have iron deficiency anemia, you're likely to start by seeing your family doctor or a general practitioner. However, in some cases, you may also be referred to a doctor who specializes in treating blood disorders (hematologist). If your doctor suspects an unknown source of bleeding, you may also be referred to a doctor who specializes in digestive tract disorders (gastroenterologist), or for women, a doctor who specializes in women's reproductive health (gynecologist).

Here's some information to help you get ready for your appointment, and what to expect from your doctor.

What you can do

  • Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
  • Write down key personal information, including any major stresses or recent life changes.
  • Make a list of all medications, as well as any vitamins or supplements, that you're taking.
  • Write down questions to ask your doctor.

Your time with your doctor is limited, so preparing a list of questions will help you make the most of your time together. For iron deficiency anemia, some basic questions to ask your doctor include:

  • What's the most likely cause of my symptoms?
  • Are there other possible causes for my symptoms?
  • Is my condition likely temporary or chronic?
  • What treatment do you recommend?
  • Are there any alternatives to the primary approach that you're suggesting?
  • I have another health condition. How can I best manage them together?
  • Are there any dietary restrictions that I need to follow?
  • Are there any brochures or other printed material that I can take with me? What Web sites do you recommend?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment anytime that you don't understand something.

What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:

  • When did you first begin experiencing symptoms?
  • How severe are your symptoms?
  • Does anything seem to improve your symptoms?
  • What, if anything, appears to worsen your symptoms?
  • Are you a vegetarian?
  • Have you recently donated blood more than once?
Tests and diagnosis

Doctors diagnose iron deficiency anemia mainly through blood tests. You doctor will check your blood for:

  • Red blood cell size and color. With iron deficiency anemia, red blood cells are smaller and paler in color than normal.
  • Hematocrit. This is the percentage of your blood volume made up by red blood cells. Normal levels are generally between 34.9 and 44.5 percent for adult women and 38.8 to 50 percent for adult men. These values may change depending on your age.
  • Hemoglobin. Normal levels of hemoglobin range between 11.1 and 15.0 grams per deciliter (111 to 150 grams per liter), depending on your age, sex and race. A lower than normal hemoglobin level indicates anemia.
  • Ferritin. This protein helps store iron in your body, and a low level of ferritin usually indicates a low level of stored iron.

Additional diagnostic tests
If your blood work indicates iron deficiency anemia, your doctor may order additional tests to identify an underlying cause. If your doctor suspects a source of bleeding within your body, you may need to have your stools tested for traces of blood. Blood in the stools is often an indicator of internal bleeding.

You may need these additional diagnostic tests:

  • Endoscopy. Doctors often check for bleeding from a hiatal hernia, bleeding ulcers and stomach bleeding with the aid of endoscopy. In this procedure, a thin, lighted tube equipped with a video camera is passed down your throat to your stomach. This allows your doctor to view your esophagus — the tube that runs from your mouth to your stomach - and your stomach to look for sources of bleeding.
  • Colonoscopy. To rule out lower intestinal sources of bleeding, your doctor may recommend a procedure called colonoscopy. A thin, flexible tube equipped with a video camera is inserted into the rectum and guided to your colon. You're usually sedated during this test. A colonoscopy allows your doctor to view some or all of your colon and rectum to look for internal bleeding.
  • Ultrasound. Women may also have a pelvic ultrasound to look for the cause of excess menstrual bleeding, such as uterine fibroids.

Your doctor may order these or other tests after a trial period of treatment with iron supplementation.

Treatments and drugs

Once you become deficient in iron to the point you develop anemia, increased intake of iron-rich foods is beneficial, but usually isn't enough to correct the problem. You need iron supplementation to build back your iron reserves, as well as to meet your body's daily iron requirements. In pregnant women, iron supplements help provide enough iron for both the mother and her fetus.

For children or adults with mild iron deficiency anemia, doctors may recommend a daily multivitamin containing iron. But typically, doctors recommend iron tablets — such as prescription ferrous sulfate tablets or an over-the-counter supplement. These oral iron supplements are usually best absorbed from an otherwise empty stomach. However, because iron can irritate your stomach, you may need to take the supplements with food. Your doctor may recommend that you take iron supplements with orange juice or with a vitamin C tablet. Vitamin C helps increase iron absorption. Additionally, take iron supplements two hours before or four hours after taking an antacid, as these medications can interfere with iron absorption.

Iron supplements can cause constipation, so your doctor may also recommend a stool softener. Iron almost always turns stools black, which is a harmless side effect. Iron can be given by injection, but this usually isn't necessary.

Iron deficiency can't be corrected overnight. You may need to take iron supplements for several months or longer to replenish your iron reserves. Generally, you'll start to feel better after a week or so of treatment. Pregnant women routinely take prescription iron supplements for the duration of their pregnancy, to prevent or treat iron deficiency anemia. Ask your doctor when you need to return to have your blood rechecked.

Depending on the mother's diet, breast milk may not contain enough iron for a growing infant. Most infant formulas contain adequate iron, but some babies require additional iron. Ask the doctor if your baby might need extra iron, but don't give additional iron without talking to your child's doctor first.

Treating causes other than poor diet
If iron supplements alone don't increase blood-iron levels in adults, it's likely the anemia is due to more than an iron-poor diet. It may be due to a source of bleeding or an iron-absorption problem that your doctor will need to investigate and treat. Depending on the cause, iron deficiency anemia treatment may involve:

  • Medications, such as oral contraceptives to lighten heavy menstrual flow
  • Antibiotics and other medications to treat peptic ulcers
  • Surgery to remove a bleeding polyp, a tumor or a fibroid

If iron deficiency anemia is severe, blood transfusions can help replace iron and hemoglobin quickly.

Prevention

You can help prevent iron deficiency anemia by eating foods rich in iron, as part of a balanced diet. Eating plenty of iron-containing foods is particularly important for people who have higher iron requirements, such as children and menstruating or pregnant women.

Foods rich in iron include:

  • Red meat
  • Pork
  • Seafood
  • Poultry
  • Eggs
  • Iron-fortified cereals, breads and pastas
  • Beans
  • Peas
  • Dark green leafy vegetables, such as spinach
  • Nuts and seeds
  • Dried fruit, such as raisins and apricots

Meat sources of iron are more readily absorbed by your body.

You can enhance your body's absorption of iron by drinking citrus juice when you eat an iron-containing food. Vitamin C in citrus juices, like orange juice, helps your body better absorb dietary iron.

Vitamin C is also found in:

  • Melon
  • Strawberries
  • Apricots
  • Kiwi
  • Mangos
  • Broccoli
  • Peppers
  • Tomatoes
  • Cabbage
  • Potatoes
  • Leafy greens

To prevent iron deficiency anemia in infants, feed your baby breast milk or iron-fortified formula for the first year. Cow's milk isn't a good source of iron for babies, and isn't recommended for infants under one year. Iron from breast milk is more easily absorbed than the iron found in formula.

ANEMIA