Dr Joel Teelucks­ingh

The teenag­er loved to eat ice at night. When the fam­i­ly com­plained that she seemed to have de­vel­oped an odd habit, she tried to stop but couldn’t.

The girl was al­so tired, ir­ri­ta­ble, strug­gling to con­cen­trate in class, breath­less climb­ing the school stairs and some­times felt her heart pound­ing at rest. Every­one had an ini­tial ex­pla­na­tion in­clud­ing stress, ex­am­i­na­tions, so­cial me­dia, seden­tary lifestyle and teenage angst. One even men­tioned the COVID vac­cine (on­ly to be told that she nev­er took it).

Then, her broth­er made a snide re­mark about her com­pul­sion to con­sume ice. There was a mo­ment of clar­i­ty.

This is the med­ical mys­tery called “pagopha­gia”, a crav­ing for ice. It be­longs to the strange fam­i­ly of be­hav­iours known as “pi­ca”, in which peo­ple per­sis­tent­ly crave or con­sume non-nu­tri­tive sub­stances like clay, soil, chalk, pa­per, starch or ash.

Pagopha­gia is strong­ly as­so­ci­at­ed with iron de­fi­cien­cy. The per­son seeks ice re­peat­ed­ly, thinks about it, car­ries it and may feel un­able to stop.

In a small study, peo­ple with iron-de­fi­cien­cy anaemia per­formed more quick­ly on a test of at­ten­tion af­ter chew­ing ice, while peo­ple with­out anaemia gained no such ben­e­fit.

Per­haps the cold and the act of chew­ing trig­ger a short-lived phys­i­o­log­i­cal wake-up call. The ice may soothe a sore tongue or mouth.

Iron is es­sen­tial for haemo­glo­bin, the mol­e­cule in red blood cells that car­ries oxy­gen. If lev­els fall, the body com­pen­sates ini­tial­ly but, even­tu­al­ly, pro­duces few­er, small­er and paler red cells. The clas­sic symp­toms of lethar­gy, short­ness of breath, headaches, dizzi­ness and pal­pi­ta­tions may be ab­sent in some peo­ple.

Our pa­tient’s blood tests con­firmed anaemia. Her red cells were small, and her fer­ritin, a mark­er of stored iron, was de­plet­ed.

The un­der­ly­ing caus­es are le­gion. Preg­nan­cy, lac­ta­tion, rapid stages of growth, gut dis­or­ders, pre­vi­ous stom­ach or in­testi­nal surgery and, in some set­tings, par­a­sitic in­fec­tion may mat­ter.

In­deed, hook­worm was the com­mon­est cause in this re­gion many years ago but good footwear and pub­lic health mea­sures have rel­e­gat­ed it to his­tor­i­cal in­ter­est. Slow bleed­ing from an ul­cer, polyp, can­cer or an­oth­er gas­troin­testi­nal le­sion can de­plete stores in­sid­i­ous­ly.

I al­ways re­mind med­ical stu­dents to ask a tact­ful men­stru­al his­to­ry. A pe­ri­od could be reg­u­lar but still be far too heavy or ex­tra­or­di­nar­i­ly painful. Un­for­tu­nate­ly, some may flood through cloth­ing or bed­ding, need to change a pad every hour or two, pass large clots, bleed for more than a week or miss school be­cause of the flow.

A past his­to­ry of easy bruis­ing and fam­i­ly mem­bers with bleed­ing dis­or­ders are al­so sig­nif­i­cant.

In 2023, Dr Nadi­ra Ram­bo­cas and the Crown Her TT team found that 76 per cent of women con­sid­ered pe­ri­od prod­ucts un­af­ford­able and 51 per cent strug­gled to ob­tain them. A re­cent $5 mil­lion fund to com­bat pe­ri­od pover­ty in this coun­try is a step in the right di­rec­tion.

In our mys­tery, the ice led to the men­stru­al his­to­ry and blood tests.

The World Health Or­gan­i­sa­tion es­ti­mat­ed that 30.7 per cent of women aged 15 to 49 were anaemic in 2023, ris­ing to 35.5 per cent among preg­nant women.

Apart from iron de­fi­cien­cy, a low haemo­glo­bin lev­el may al­so re­sult from vi­t­a­min de­fi­cien­cies, in­fec­tion, in­flam­ma­tion, kid­ney dis­ease, au­toim­mune phe­nom­e­na and in­her­it­ed dis­or­ders such as sick­le cell dis­ease or tha­las­saemia.

Heavy men­stru­a­tion may be the lead­ing ex­pla­na­tion in a young woman but in men and post­menopausal women, un­ex­plained iron-de­fi­cien­cy anaemia is of­ten a red flag to pos­si­ble gas­troin­testi­nal blood loss or can­cer.

Oral iron is ef­fec­tive for many peo­ple but nau­sea, ab­dom­i­nal dis­com­fort, con­sti­pa­tion or dark stools are ad­verse ef­fects.

In­tra­venous iron may be ap­pro­pri­ate when tablets are not tol­er­at­ed, ab­sorp­tion is poor, re­place­ment is ur­gent or loss­es con­tin­ue.

Heavy men­stru­al bleed­ing may re­quire blood trans­fu­sion, hor­mon­al treat­ment, tranex­am­ic acid, as­sess­ment for fi­broids or in­ves­ti­ga­tion for a bleed­ing dis­or­der.

Please do not turn a crav­ing for ice in­to a rea­son to buy iron blind­ly. Too much iron can be harm­ful and these bright red tablets are par­tic­u­lar­ly dan­ger­ous if swal­lowed by young chil­dren.

The den­tists will al­ways warn that chew­ing hard ma­te­ri­als is not harm­less ei­ther. Teeth are not built to crush ice cubes all day as enam­el cracks, fill­ings break and sen­si­tiv­i­ty wors­ens.

When iron de­fi­cien­cy is prop­er­ly treat­ed by a physi­cian, the ab­nor­mal crav­ing can fade with re­mark­able speed.

Med­i­cine of­ten be­gins with symp­toms that sound too or­di­nary to mat­ter. Peo­ple hide pi­ca be­cause they fear be­ing laughed at. A child eat­ing chalk may be pun­ished. A preg­nant woman crav­ing clay may be told it is mere­ly one of those things.

Par­ents and teach­ers should pay at­ten­tion when a child or teenag­er be­comes un­usu­al­ly tired, pale, breath­less, with­drawn or un­able to con­cen­trate. Ask about di­et, pe­ri­ods and un­usu­al crav­ings.

Lis­ten close­ly in clin­ics, class­rooms and kitchens. When some­one can­not stop chew­ing ice, the body may be silent­ly telling the tale be­fore the di­ag­no­sis is made.