Signs and symptoms

In general, anemia causes fatigue (to the point of exhaustion), paleness of the skin, weakness, shortness of breath with only mild exertion, lightheadedness, and often coldness in the hands and feet.

Signs and symptoms of iron deficiency anemia in particular include:

• Cracks in the sides of the mouth
  
  
• Inflammation or soreness of the tongue
  
  
• Brittle nails
  
  
• Unusual cravings for non-nutritive food, such as for ice, dirt, paint or pure starch
  
  
• Headache
  
  
• Poor appetite — in infants and children with iron deficiency anemia
  
  
• Susceptibility to infection — in infants and children with iron deficiency anemia

Children and adults with iron deficiency anemia may also experience restless legs syndrome — an uncomfortable tingling or crawling feeling in the legs that's relieved by walking.

If you or your child develops signs and symptoms suggestive of iron deficiency anemia, see your doctor. Initially, iron deficiency anemia can be so mild as to go unnoticed. But as the body becomes more deficient in iron and anemia progresses, signs and symptoms increase.

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Causes

Among other functions, your blood transports oxygen throughout your body.

Blood consists of a liquid called plasma. Floating within plasma are three types of blood cells — red blood cells, white blood cells and platelets. White blood cells fight infection. Platelets help blood to clot after a cut. Red blood cells, which are the most abundant of the three types, give blood its red color. They're also responsible for carrying oxygen from your lungs, via your bloodstream, to all of the organs and the tissues in your body.

Red blood cells contain hemoglobin, an iron-rich substance. Hemoglobin is the substance that enables red blood cells to carry oxygen from the lungs to all parts of your body.

Red blood cells are manufactured in your bone marrow — a red, spongy material found within the cavities of many of your large bones, such as your pelvic bones. Your bone marrow needs iron, along with vitamins, to produce hemoglobin and red blood cells.

Your body gets vitamins and iron, which are also important for building muscle, from the foods you eat. Your body also recycles iron from old red blood cells. The amount of iron in your body depends on your intake, loss and storage of the mineral.

You can be mildly deficient in iron and not develop anemia. Occasionally, your diet may be low in iron. But your body keeps a reserve of iron to cover such temporary shortages.

Iron deficiency leads to anemia when the body lacks sufficient iron to make adequate hemoglobin. Without enough hemoglobin, your red blood cells are smaller and paler than normal, and they can't carry adequate oxygen to your tissues.

Causes of iron deficiency anemia include:

• Blood loss. Blood contains iron within red blood cells. If you lose blood, you lose some iron. Women with heavy periods who lose a lot of blood during menstruation are at risk of iron deficiency anemia. Slow, chronic blood loss from a source within the body — such as a peptic ulcer; a hiatal hernia; a kidney, ovarian or bladder tumor; a colon polyp; colorectal cancer; or uterine fibroids — can cause iron deficiency anemia. Gastrointestinal bleeding from regular use of aspirin or nonsteroidal anti-inflammatory medications (NSAIDs) or bleeding from hemorrhoids also can be a source of iron loss and anemia. Blood loss from within the body may show up in your stools, producing black or bloody stools. Alert 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. Examples of iron-rich foods include meat, eggs and whole-grain or iron-fortified foods. Infants and children need iron from their diet, too. Consuming too little iron in your diet over time can cause a deficiency in iron.
  
  
• 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 (sprue), that 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 nutrients such as iron. Some medications may interfere with iron absorption. For example, regular use of prescription-strength stomach acid blockers called proton pump inhibitors (Prilosec, Aciphex) may lead to iron deficiency anemia. Stomach acid, which these products suppress, is needed 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 virtually all pregnant women because their iron stores need to serve the increased blood volume of the mother 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.

Pregnancy Center Peptic ulcer Hiatal hernia Colorectal cancer Uterine fibroids Hemorrhoids Inflammatory bowel disease

Risk factors

These factors may increase the risk of iron deficiency anemia:

• You're a woman who has heavy periods.
  
  
• You're pregnant and not taking iron supplements prescribed by your doctor.
  
  
• Your diet or your child's diet is consistently low in iron.
  
  
• You have a known or hidden source of bleeding within your body, such as an ulcer, a bleeding tumor, a uterine fibroid, a colon polyp, a hiatal hernia, colorectal cancer, gastrointestinal bleeding or hemorrhoids.

Women in general are at greater risk of iron deficiency anemia because their bodies store less iron than men's and because they lose blood each month during menstruation. Infants who don't get enough iron in their milk or formula may risk deficiency. Children need extra iron during growth spurts, because iron is also important for muscle development. If your child isn't eating a healthy, varied diet, he or she may be at risk of anemia.

In healthy men and postmenopausal women, however, iron deficiency typically points to bleeding somewhere in the gastrointestinal tract.

Donating blood — a source of blood loss — usually isn't a risk factor for iron deficiency anemia. However, some people learn that their hemoglobin is low, which indicates anemia, when they go to donate blood. Low hemoglobin may be a temporary problem remedied by eating more iron-rich foods. However, 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.

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Screening and diagnosis

Doctors diagnose iron deficiency anemia mainly through blood tests. These may include tests to examine the size and color of your red blood cells. With iron deficiency anemia, red blood cells are smaller and paler in color than normal.

Your doctor will check your hematocrit — the percentage of your blood volume made up by red blood cells — and iron levels (hemoglobin). Your hemoglobin is considered low if it's less than 10 grams per deciliter (g/dL) for women and 12 g/dL for men.

In addition, blood tests for iron deficiency anemia typically include a measurement of ferritin, a protein that helps store iron in the body. A low level of ferritin usually indicates a low level of iron.

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

Additional diagnostic tests such as these may be necessary:

• 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 upper stomach, looking for sources of bleeding.
  
  
• Colonoscopy. To rule out intestinal sources of bleeding, your doctor may recommend a procedure called colonoscopy. A thin, flexible tube is inserted through the rectum and into your colon. You're usually sedated during this test. A colonoscopy allows your doctor to view some or all of your colon and rectum, looking for sources of bleeding.

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

Colonoscopy

Complications

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

Untreated, iron deficiency anemia may lead to a rapid or irregular heartbeat (arrhythmia). The heart must pump more blood to compensate for the lack of oxygen in the blood when you're anemic. In people with coronary artery disease — narrowing of the arteries that feed the heart — unchecked anemia can lead to angina. Angina is chest pain caused by decreased oxygen and blood flow to the heart muscle. In severe cases of untreated anemia, the heart muscle may become permanently injured or weakened.

In pregnant women, severe iron deficiency anemia has been linked to premature births and low-birth-weight babies. But the condition is easily preventable and treatable in pregnant women who receive prenatal care.

In infants and children, severe iron deficiency can lead to anemia as well as resulting in delayed growth.

Iron deficiency anemia can recur, so follow-up visits to your doctor may be recommended.

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Treatment

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

For children or adults with mild iron deficiency anemia, your doctor may recommend a daily multivitamin containing iron. But typically, iron tablets — such as prescription ferrous sulfate tablets or an over-the-counter supplement called Vitron-C — are recommended. These oral iron supplements are usually best absorbed on an empty stomach. However, because iron can cause stomach irritation, you may need to take them with food. There are coated versions of iron tablets that are easier on the stomach. But ask your doctor if they're right for you. Your doctor may recommend that you take iron supplements with orange juice or with a vitamin C tablet. Vitamin C in orange juice or supplement form helps increase iron absorption. Iron supplements can cause constipation, so your doctor may recommend a stool softener or a laxative for you. Iron almost always turns stools black, which is a harmless side effect. Iron can be given by injection, but this isn't usually necessary.

Iron deficiency can't be cured overnight. You may need to take iron supplements for several months or longer to replenish your body's iron reserves. Pregnant women are routinely prescribed iron supplements for the duration of their pregnancy to prevent or treat iron deficiency anemia.

Some infants may require supplemental iron. Breast milk and cows' milk may not contain enough iron for a growing infant. Most infant formulas contain adequate iron, but some babies require additional iron. Ask your baby's doctor about your child's iron requirements.

If you think you or your child may be anemic, see your doctor. Iron deficiency anemia isn't something you should self-diagnose or treat. Iron supplements should be taken under a doctor's supervision. Overloading the body with iron can be serious. Excess iron accumulation can damage the liver, among other complications.

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 needs to be investigated and treated.

If chronic blood loss is to blame, the source of the bleeding must be located and corrected. This may involve treatment with medications such as oral contraceptives to lighten heavy menstrual flow or antibiotics to treat ulcers, or surgery to remove a bleeding polyp, a tumor, or a fibroid. Malabsorption problems may be treated with medications to manage an underlying disease.

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

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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 high iron requirements, such as children and menstruating or pregnant women.

Foods rich in iron include red meat (especially liver), fish, chicken and eggs. Meat sources of iron are called heme-iron sources and are easily absorbed by the body. Plant-based foods also are good sources of iron, although they're less easily absorbed. Among the best are whole-grain or iron-fortified cereals, breads and pastas. Beans and peas, dark green, leafy vegetables (spinach and Swiss chard, for example), dried fruit, raisins, nuts, and seeds also contain iron.

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 from animals and plants.

— July 19, 2001 —