Pagophagia

Pagophagia
SymptomsCompulsive consumption of ice
ComplicationsDental injury, worsening iron deficiency or other micronutrient deficiency, hyponatremia
CausesUnknown etiology
Risk factorsIron-deficiency anemia, psychological distress, pregnancy
Diagnostic methodBased on signs and symptoms presented and blood tests such as a complete blood count
TreatmentIron supplementation

Pagophagia (from Greek: pagos, frost/ice, + phagō, to eat[1]) is the compulsive consumption of ice or iced drinks.[2] It is a form of the disorder known as pica, which in Latin refers to a magpie that eats everything indiscriminately.[3] Its medical definition refers to the persistent consumption of nonnutritive substances for over a period of at least one month.[3] However, different studies have included alternative definitions including "daily consumption of 2-11 full glasses of ice (480-2640g)" or "the purposeful ingestion of at least one ordinary tray of ice daily for a period in excess of two months."[4] Pagophagia has been shown to be associated with iron-deficiency anemia[5] and responsive to iron supplementation,[6][7] leading some investigators to postulate that some forms of pica may be the result of nutritional deficiency.[8]

Similarly, folk wisdom also maintained that pica reflected an appetite to compensate for nutritional deficiencies, such as low iron or zinc. In iron deficient pregnant persons who experience symptoms of pagophagia, decreased cravings for ice have been observed after iron supplementation.[9] Later research demonstrated that the substances ingested by those who have pica generally do not provide the mineral or nutrient in which people are deficient. In the long run, as people start consuming more nonfoods compulsively, pica can also cause additional nutritional deficiencies.[9]

A hypothesis of the neurological basis of pagophagia was proposed in a 2014 study in which those with iron deficiency anemia were shown to have improved response times while performing on a neuropsychological test when given ice to chew on. As a result, the researchers hypothesized that chewing on ice causes vascular changes that allow for increased perfusion of the brain, as well as activation of the sympathetic nervous system, which also increases blood flow to the brain, allowing for increased processing speed and alertness.[10]

Although some investigators[8] also hypothesize that chewing ice may lessen pain in glossitis and stomatitis related to iron-deficiency anemia, the specific pathophysiology is still unknown and this hypothesis remains controversial.[11] The American Dental Association recommends not chewing ice as it can lead to dental injury and suggests that ice should be allowed to melt in the mouth instead.[12]

Signs and symptoms

The main symptom for pagophagia is intense cravings for chewing ice.[13] Those with pagophagia will find themselves constantly chewing on ice cubes, shaved ice or even frost from the fridge.[14] Since a common underlying cause of pagophagia is iron-deficiency anemia, many people with the disorder will also experience weakness, fatigue, pallor, sore tongue, dizziness, headache, and cold extremities.[13] Other symptoms associated with iron deficiency may include brittle nails, cracking at the corner of the mouth, and restless legs syndrome.[15] Severe cases of iron deficiency can also cause the body to make up for decreased oxygen-carrying capacity of the blood by increasing cardiac output. Thus, palpitations, angina, as well as shortness of breath may also present, specially if there is a preexisting cardiovascular disease or condition.[16] Excess water intake from any source can lead to hyponatremia and has been noted in at least one case study.[17]

Causes

Iron deficiency

Although compulsive consumption of ice is frequently associated with a deficiency of iron, the exact etiology of this form of pica is not well-understood. There is one hypothesis that states consumption of ice activates a vasoconstrictive response which causes an increase of blood flow to the brain. Because fatigue is the most common symptom experienced in iron-deficiency anemia due to decreased levels of oxygen delivered to the brain, the increase of blood flow to the brain through consumption of ice is thought to increase alertness and improve the symptoms of fatigue. In support of this hypothesis, individuals with iron-deficient anemia were found to have improved response times on neuropsychological tests than compared to healthy controls when chewing ice.[4]

Reports have demonstrated the improvement or resolution of pagophagia when given iron supplementation.[18] People with iron-deficiency anemia who showed symptoms of pagophagia had complete resolution of their symptoms when their iron levels were treated, suggesting the association between serum iron levels and symptoms of pagophagia. In another case, an individual who presented with pagophagia was prescribed 325mg tablets of ferrous sulfate twice daily. The individual was also administered 1000mg of low molecular weight dextran over 1 hour and their symptoms of pagophagia were immediately resolved.[15] In another case, a woman with iron-deficiency anemia related to gynecological bleeding was admitted and her dietary screening showed consumption of about 80 ice cubes for day for the past 5 years. She was given iron supplementation and her anemia was treated along with the disappearance of pagophagia within two weeks.[19]

One study looked at the relationship between pagophagia and H. pylori infection in those with iron deficiency anemia. It was found that pagophagia does not increase the risk of H. pylori infections in that specific population. In addition, H. pylori infection and pagophagia did not have a synergistic effect on the development of iron absorption abnormalities in the intestines.[20]

Calcium deficiency

Pagophagia has been often reported with calcium deficiency but its pathophysiology is unknown.[21]

Psychological and physiological distress

In several cases, pagophagia has been associated with certain psychological conditions such as compulsive behavior or depressive disorder where pagophagia was used as a coping mechanism to deal with psychological stress.[17] Some suggestions for other causes of pagophagia include hunger and gastrointestinal distress related to ways the body attempts to ease the stress.[22]

Other known risk factors for pica include "stress, cultural factors, learned behavior, low socioeconomic status, underlying mental health disorder, nutritional deficiency, child neglect, pregnancy, epilepsy, [and] familial psychopathology."[23]

In one case report, a 42-year-old lady presented with complaints of freezer frost and eating ice. She developed a habit of eating 10 to 12 ice cubes and freezer frost each day, and eventually increased her consumption to 25 to 30 ice cubes each day. Her medical assessment revealed no past or family history of any chronic psychiatric disorder or physical disorder. Her hemoglobin, serum calcium, and stool examination were normal. One suspected cause of her pagophagia was psychological stress, the stressor being her son's annual examinations. The lady was previously prescribed venlafaxine 50mg and vitamin B-complex for two to six weeks but with no improvement. The doctor initiated fluoxetine 20mg daily for her and the venlafaxine was tapered off. The dose was increased to 30mg after three weeks and counseling and behavioral treatment was given. Her pagophagia resolved after four months. Along with this case, previous reports have shown selective serotonin reuptake inhibitors effective in treating pagophagia. Counseling and behavioral strategies such as positive and negative reinforcement should be utilized for people with psychiatric conditions. [21]

Diagnosis

Pagophagia may often go undiagnosed as those with the condition may consider it to be harmless and not seek medical help unless the behavior begins to interfere with their lives. However, the disorder is not as harmless as it seems since underlying medical causes that remain undiagnosed may lead to complications. For example, if anemia is not treated properly, the heart will need to exert more force in order to supply adequate oxygen throughout the body which can progress to heart failure.[16] Other complications of pagophagia include tooth sensitivity and dental injury leading to cracked or chipped teeth. Overconsumption of ice may cause bloating, gas, and stomach pain. Imaging exams such as abdominal x-rays and endoscopy may be ordered if a person presents with abdominal symptoms.[24]

Due to the relation between pagophagia and iron deficiency anemia, diagnosis begins with obtaining a medical history, a physical exam as well as blood tests that includes a complete blood count and additional tests to determine levels of hemoglobin, hematocrit,serum iron, and ferritin, a protein that helps the body store iron.[25] In individuals that are anemic, the tests would show results with lower than normal levels which would then confirm the diagnosis. If a blood slide is ordered by the doctor, it may show red blood cells that are smaller and paler than normal cells.[26] In the case of severe iron deficiency, white blood cell count may also be low.[26]

A differential diagnosis for psychiatric conditions should be performed in the setting of pagophagia. Schizophrenia and psychosis, other eating disorders, substance use, and autism should be considered in the differential diagnosis.[4]

Implications for practice

When screening for suspected pagophagia, it may be appropriate to include screening for iron deficiency. Screening for pagophagia may help clinicians gather valuable information towards the diagnosis and treatment, especially populations who are at risk, for iron deficiency. Women who are menstruating, pregnant, or lactating may benefit from pagophagia screening because of the high occurrence of iron deficiency in these groups. Other groups at risk due to prevalence of iron deficiency include blood donors, individuals who are post-surgery or trauma, or people who experience malabsorption of iron.[4] Collecting information during health screening to determine any causes of blood loss, malabsorption of iron from the diet, and any laboratory tests to determine iron deficiency may be appropriate in people who present with symptoms of pagophagia. If iron deficiency is confirmed by laboratory screening, iron replacement therapy can be considered with oral supplementation. Over the counter or prescription formulations of iron containing ferrous gluconate, ferrous sulfate, or ferrous fumarate are available.

Epidemiology

Pagophagia in iron-deficiency anemia

In one study of pica in iron deficient versus iron replete blood donors, "pica was reported in 11% of donors with iron depletion/deficiency, compared with 4% of iron-replete donors," with pagophagia accounting for 94% of reported pica cases.[27] A case series of pagophagia in men with iron-deficiency anemia concluded "that pagophagia occurred in 34% of men with iron-deficiency anemia." Men who were older and had higher platelet counts were less likely to have pagophagia compared to younger men and those with lower platelet counts.[28]

Pregnancy

In women, pica is "most often seen during pregnancy," with estimates of 27.8% of pregnant women experiencing pica, but pica prevalence and manifestation is culturally and geographically heterogenous.[23] A study of pregnant women in Tehran, Iran found pica in 8.33% of the study population with pagophagia accounting for 76% of observed pica cases. Logistic regression showed a positive correlation between pica in pregnancy with pregnancy complications, lower educational attainment, and use of iron supplementation.[29] A study of pica in pregnant Mexican-born women living in either the United States or Mexico found differing rates of pagophagy between the two groups.[30]

Children

A meta-analysis of the prevalence of pica in German children found that 12.3% of German children "have engaged with a pica behavior at some point in their lives," but did not specify the types of pica observed.[23] Despite pica being observed in young children, it is important to note that it is also a common eating disorder among those who are intellectually impaired.[23] Thus, proper diagnosis of pica is essential, requiring the children to be at least above two years of age, as it is more common to see children younger than two consuming nonnutritive substances.[23] In children, pica is usually short term and will disappear spontaneously.[23] In terms of studies regarding a specific type of pica, a cross-sectional study of American children receiving chronic hemodialysis therapy found that 34.5% of the children studied engaged in pagophagy compared to 12.6% of children who engaged in other forms of pica.[31]

References

  1. ↑ " pagophagia at The Free Dictionary
  2. ↑ Parry-Jones, B. (1993). "Pagophagia, or compulsive ice consumption: a historical perspective". Psychol Med. 22 (3): 561–71. doi:10.1017/s0033291700038022. PMID 1410082.
  3. 1 2 Diagnostic and Statistical Manual of Mental Disorders. Psychiatry Online: American Psychiatric Association. 2014.
  4. 1 2 3 4 Rabel, Antoinette; Leitman, Susan F.; Miller, Jeffery L. (2016). "Ask about ice, then consider iron". Journal of the American Association of Nurse Practitioners. 28 (2): 116–120. doi:10.1002/2327-6924.12268. ISSN 2327-6886. PMC 4635104. PMID 25943566.
  5. ↑ Borgna-Pignatti, Caterina; Zanella, Sara (2016). "Pica as a manifestation of iron deficiency". Expert Review of Hematology. 9 (11): 1075–1080. doi:10.1080/17474086.2016.1245136. ISSN 1747-4086. PMID 27701928. S2CID 19221253.
  6. ↑ Ilan Brat (2008). "Chew This Over: Munchable Ice Sells Like Hot Cakes". Wall Street Journal. Retrieved 2008-01-31.
  7. ↑ Osman YM, Wali YA, Osman OM (2005). "Craving for ice and iron-deficiency anemia: a case series from Oman". Pediatr Hematol Oncol. 22 (2): 127–31. doi:10.1080/08880010590896486. PMID 15804997. S2CID 34338417.
  8. 1 2 Reynolds, Ralph D. (1968). "Pagophagia and Iron Deficiency Anemia". Annals of Internal Medicine. 69 (3): 435–440. doi:10.7326/0003-4819-69-3-435. ISSN 0003-4819. PMID 5244572.
  9. 1 2 Gavin, Mary L., MD. Pica. KidsHealth for Parents. December 2007.
  10. ↑ Hunt, Melissa G.; Belfer, Samuel; Atuahene, Brittany (2014). "Pagophagia improves neuropsychological processing speed in iron-deficiency anemia". Medical Hypotheses. 83 (4): 473–476. doi:10.1016/j.mehy.2014.07.016. ISSN 0306-9877. PMID 25169035.
  11. ↑ Mesa, Ruben, MD. Craving and chewing ice: A sign of Anemia?, MayoClinic.com.
  12. ↑ The American Dental Association. Chew on This: Crunching Ice Can Be Bad for Your Teeth. colgate.com, 2006.
  13. 1 2 "Pagophagia: Causes, Treatment, and More". Healthline. 2017. Retrieved 2021-07-29.{{cite web}}: CS1 maint: url-status (link)
  14. ↑ "What is Pagophagia?". WebMD. 2021. Retrieved 2021-07-29.{{cite web}}: CS1 maint: url-status (link)
  15. 1 2 Auerbach, Michael; Adamson, John W. (2016). "How we diagnose and treat iron deficiency anemia". American Journal of Hematology. 91 (1): 31–38. doi:10.1002/ajh.24201. ISSN 1096-8652. PMID 26408108.
  16. 1 2 Weksler, Babette (2017). Wintrobe's Atlas of Clinical Hematology. Lippincott Williams & Wilkins. p. PT105. ISBN 9781451154542.
  17. 1 2 Bedanie, Genanew; Tikue, Alay G; Thongtan, Thanita; Zitun, Mohamed; Nugent, Kenneth (2020). "Pica/Pagophagia-Associated Hyponatremia: Patient Presenting With Seizure". Cureus. 12 (7): e9330. doi:10.7759/cureus.9330. ISSN 2168-8184. PMC 7384452. PMID 32742885.
  18. ↑ Borgna-Pignatti, Caterina; Zanella, Sara (2016). "Pica as a manifestation of iron deficiency". Expert Review of Hematology. 9 (11): 1075–1080. doi:10.1080/17474086.2016.1245136. ISSN 1747-4094. PMID 27701928. S2CID 19221253.
  19. ↑ Sontag, C.; Kettaneh, A.; Fain, O.; Eclache, V.; Thomas, M. (2001). "[Rapid regression of prolonged pagophagia after treatment of iron deficiency]". Presse Médicale. 30 (7): 321–323. ISSN 0755-4982. PMID 11262806.
  20. ↑ Asma, Suheyl; Boga, Can; Ozdogu, Hakan; Serin, Ender (2009). "The association of pagophagia with Helicobacter pylori infection in patients with iron-deficiency anemia". International Journal of Hematology. 90 (1): 28–32. doi:10.1007/s12185-009-0360-z. ISSN 1865-3774. PMID 19543687. S2CID 10700327.
  21. 1 2 Bhatia, M.S. (2014). "Pagophagia – A Common but Rarely Reported Form of Pica". Journal of Clinical and Diagnostic Research. 8 (1): 195–196. doi:10.7860/JCDR/2014/6829.3959. PMC 3939500. PMID 24596772.
  22. ↑ Gluckman, Peter; Hanson, Mark; Seng, Chong Yap; Bardsley, Anne (2015). Nutrition and Lifestyle for Pregnancy and Breastfeeding. Oxford University Press. ISBN 978-0-19-872270-0.
  23. 1 2 3 4 5 6 Al Nasser, Yasser; Muco, Erind; Alsaad, Ali J. (2021), "Pica", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 30335275, retrieved 2021-07-29
  24. ↑ Britten, Lisa J. Ice Eating Addiction: Ice Eating Addiction.
  25. ↑ "Iron-Deficiency Anemia". www.hematology.org. Retrieved 2021-07-29.
  26. 1 2 "Iron deficiency anemia - Diagnosis and treatment - Mayo Clinic". www.mayoclinic.org. Retrieved 2021-07-29.
  27. ↑ Bryant, Barbara J.; Yau, Yu Ying; Arceo, Sarah M.; Hopkins, Julie A.; Leitman, Susan F. (2013). "Ascertainment of Iron Deficiency and Depletion in Blood Donors through Screening Questions for Pica and Restless Legs Syndrome". Transfusion. 53 (8): 1637–1644. doi:10.1111/trf.12061. ISSN 0041-1132. PMC 3691288. PMID 23305102.
  28. ↑ Barton, James C.; Barton, J. Clayborn; Bertoli, Luigi F. (2019). "Pagophagia in men with iron-deficiency anemia". Blood Cells, Molecules and Diseases. 77: 72–75. doi:10.1016/j.bcmd.2019.04.002. PMID 30986649.
  29. ↑ Ezzeddin, Neda; Zavoshy, Rosa; Noroozi, Mostafa; Jahanihashemi, Hassan; Riseh, Shaghayegh Hadizadeh (2015). "Prevalence and risk factors for pica during pregnancy in Tehran, Iran". Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity. 20 (4): 457–463. doi:10.1007/s40519-015-0198-8. ISSN 1124-4909. PMID 26143570. S2CID 25439995.
  30. ↑ Lin, Janice W.; Temple, Luisa; Trujillo, Celina; Mejia-Rodriquez, Fabiola; Rosas, Lisa Goldman; Fernald, Lia; Young, Sera L. (2015). "Pica during pregnancy among Mexican-born women: a formative study: Pica among Mexican women". Maternal & Child Nutrition. 11 (4): 550–558. doi:10.1111/mcn.12120. PMC 4216644. PMID 24784797.
  31. ↑ Katsoufis, Chryso Pefkaros; Kertis, Myerly; McCullough, Judith; Pereira, Tanya; Seeherunvong, Wacharee; Chandar, Jayanthi; Zilleruelo, Gaston; Abitbol, Carolyn (2012). "Pica: An Important and Unrecognized Problem in Pediatric Dialysis Patients". Journal of Renal Nutrition. 22 (6): 567–571. doi:10.1053/j.jrn.2011.10.038. PMID 22296917.
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