What causes ice cravings in individuals with iron deficiency anemia?

Ice Craving (Pagophagia) in Iron Deficiency Anemia

Ice craving (pagophagia) in iron deficiency anemia is a recognized clinical manifestation of the condition, characterized by compulsive consumption of ice that typically resolves with iron replacement therapy before hemoglobin levels fully normalize. 1, 2

Mechanism and Presentation

• Pagophagia is defined as the compulsive and repeated ingestion of ice, which is a specific form of pica (craving and consumption of non-nutritive substances) commonly associated with iron deficiency anemia 2
• This symptom appears to be relatively common, affecting approximately 16% of patients with iron deficiency anemia according to some studies 2
• Pagophagia is considered a specific clinical manifestation of iron deficiency, alongside other symptoms such as angular stomatitis, glossitis, koilonychia, restless legs syndrome, and blue sclerae 1

Pathophysiological Basis

• While the exact pathophysiological mechanism behind ice craving in iron deficiency remains unclear, it likely involves the central nervous system 2
• Iron deficiency affects multiple organ systems, including neurological function, which may explain these unusual cravings 3
• The craving for ice specifically (rather than other non-nutritive substances) may be related to:
  • Potential oral or glossal inflammation relief from the cold sensation 1
  • Possible neurological pathway alterations due to iron's role in neurotransmitter function 2

Clinical Significance

• Pagophagia can serve as a clinical clue to underlying iron deficiency, even before anemia develops 3
• The presence of this symptom should prompt investigation for iron deficiency, especially when accompanied by other symptoms like fatigue, exercise intolerance, or difficulty concentrating 3
• Pica behaviors (including pagophagia) are reported in approximately 40-50% of patients with iron deficiency anemia 3

Resolution with Treatment

• A key diagnostic feature of pagophagia related to iron deficiency is that it typically resolves with iron replacement therapy 2
• Interestingly, the resolution of ice craving often occurs before normalization of hemoglobin levels, suggesting it may be more directly related to tissue iron levels than to anemia itself 2
• This early resolution can serve as a clinical indicator of successful iron repletion 2

Diagnostic Approach

• When pagophagia is identified, iron studies should be performed, including serum ferritin (the most powerful test for diagnosing iron deficiency) 4
• A serum ferritin level below 30 ng/mL is typically diagnostic of iron deficiency in the absence of inflammatory conditions 3
• In the presence of inflammation, transferrin saturation less than 20% may be a more reliable indicator 3

Treatment Implications

• The primary treatment for pagophagia is addressing the underlying iron deficiency through iron supplementation 2
• Oral iron (such as ferrous sulfate) is typically first-line therapy for most patients 3
• Intravenous iron may be indicated in cases of oral iron intolerance, poor absorption, chronic inflammatory conditions, or ongoing blood loss 3

Remember that while pagophagia is a recognized symptom of iron deficiency, its presence should trigger a comprehensive evaluation to identify the underlying cause of the iron deficiency, which may include gastrointestinal blood loss, menstrual blood loss, malabsorption, or inadequate dietary intake 4, 3.